PAY  TO  THE  ORDER  OF 

Orange  Counly  Savings  a; id  Trusl  C«. 

Dn.  J.  M-  EURUE-^A/ 

J.  M.  BURLEIAA/ 


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PAY  TO  TVtP;  OPDEI?  or 
Pnnge  Cmnif  S^.j/i^j  s.  di  Trmi  C#. 
Oil.  J.  M.  BUR/LEIW 
iil^A4^  BURLCW 


ENLARGEMENT  OF  THE  PROSTATE 

DEAVER 


BY  THE  SAME  AUTHOR 


APPENDICITIS 

Its  Diagnosis  and  Treatment. 

Fourth  Revised  Edition.    Illustrated. 

Octavo.     Cloth  $5.00. 

By  John  B.  Deaver,  M.D.,  and 

ASTLEY  P.   C.  AsHHURST,  M.D. 


SURGERY  OF  THE  UPPER  ABDOMEN 

Second  Edition.     "With  9   Colored  Plates  and  198 

Text  Illustrations. 

Octavo,     Cloth  $11.00. 

By  John  B.  Deaver,  M.D.,  and 
Joseph  McFarland,  M.D. 


THE  BREAST 

Its  Anomalies,  Diseases  and  Their  Treatment. 

With  8  Colored  Plates  and  285  Text  Illustrations. 

Octavo,     Cloth  $11.00. 

P.  BLAKISTON'S  SON  &  CO, 
PHILADELPHIA 


Median  Sagittal  Section  of  the  Pelvis  and  the  Lower  Abdomen,  Showing  the 
General  Relations  of  the  Prostate  to  the  Bladder,  the  Urethra,  and  the 

Rectum. 


ENLARGEMENT 
OF  THE  PROSTATE 


Its  History,  Anatomy,  Etiology,  Pathology,  Clinical   Causes 

Symptoms,  Diagnosis,  Prognosis,  Treatment;  Tech- 

NiQiJE  OF  Operations,  and  After-treatment 

JOHN  B.  DEAVER,  M.D.,  LL.D.,  ScD.,  F.A.C.S. 

John  Rea  Barton  Professor  of  Surgery,  University  of  Pennsylvania;  Surgeon-in-Chief  to  the 
Lankenau  Hospital,  Philadelphia 

ASSISTED  BY 

LEON  HERMAN,  B.S.,  M.D. 

Urologist  to  the  Methodist  Episcopal  Hospital,  Philadelphia;  Assistant  Surgeon  to  the  Penn- 
sylvania Hospital,  Philadelphia;  Instructor  in  Urology,  University  of  Pennsylvania 


SECOND  EDITION 
WITH  142  ILLUSTRATIONS 


PHILADELPHIA 

P.    BLAKISTON'S    SON    &    CO. 

I0I2  WALNUT  STREET 


VJT75X. 


Copyright  December,  1922,  by  P.  Blakiston's  Son^&  Co. 


PRINTED    IN    U.   S.  A. 
lY    THE    MAPLE    PRESS    YORK    PA 


TO   THE    MEMORY   OF 

J.  B.  D.,  Jr. 

WHO  DEPARTED   THIS   LIFE   AT    THE   THRESHOLD   OF   MA>JHOOD,    AND    WHO 
I    HAD    HOPED   WOULD   TRAVEL   IN   MY   FOOTSTEPS 
THIS   BOOK   IS   AFFECTIONATELY   DEDICATED 


PREFACE  TO  THE  SECOND  EDITION 


Since  the  appearance  of  the  first  edition  of  this  book,  the  surgery  of 
prostatic  obstruction  has  been  perfected  to  a  remarkable  degree.  The 
underlying  principles  of  prostatectomy  however,  have  not  changed 
materially. 

It  is  an  impressive  fact  that  the  operation,  which,  we  advised  in  the 
previous  edition,  should  be  performed  "only  after  all  palliative  means 
had  been  tried  without  success,"  is  now  justifiable  as  a  primary  pro- 
cedure, and  one  far  safer  in  the  average  case  than  any  form  of  palliation. 
This  radical  change  in  point  of  view  is  dependant  upon  factors  other 
than  the  mere  technical  problems  involved,  and  it  was  with  this  thought 
in  mind  that  the  present  revision  was  made. 

The  reader  who  desires  to  learn  the  technique  of  prostatectomy  will 
^  find  ample  descriptions  of  the  various  methods  employed ;  he  will  find, 
Vinoreover,  a  practical  discussion  of  the  preoperative  and  postoperative 
"^  methods  of  treatment. 

It  has  been  our  aim  to  make  the  book  essentially  practical,  there- 

VJore,  we  have  omitted  in  large  part,  theoretical  considerations,  and  for 

tne  same  reason,  have  preferred  to  omit  many  proposed  refinements 

iv^  oirtechnique,  which  are,  in  our  opinion,  of  minor  value.     Further,  we 

" -^  have  confined  our  descriptions  to  those  laboratory  tests  which  have 

proved  personally  satisfactory  in  our  daily  work. 

The  chapter  on  diagnosis  has  been  fully  revised  and  a  section  on 
N:  the  use  of  the  cystoscope  in  prostatic  hypertrophy  added.     The  section 
^  on  embryology  has  been  rewritten  and  the  physiological    problems 
Vjyrelated  to  prostatic  enlargement  are  dealt  with  in  a  separate  chapter. 
In  the  present  edition  the  question  of  prognosis  is  discussed  at  consid- 
erable length,   our  conclusions  being  based  on  the  study  of  a  large 
series  of  collected  cases.     Herein  is  shown  the  comparative  importance 
of  the  various  phases  of  treatment,  the  overwhelming  importance  of 
painstaking  preoperative  treatment,  and  the  comparative  mortality  and 
morbidity  rates  with  the  different  operative  techniques.     Comparison 
is  made  between  the  operative  mortality,  as  reported  by  recognized 
leaders  in  prostatic  surgery,  with  that  obtaining  at  less  experienced 

ix 


X  Preface 

hands.  A  careful  survey  of  the  figures  presented  will  promote  caution 
and  care  in  the  practice  of  this  important  branch  of  surgery. 

The  two-stage  operation  of  supra-pubic  prostatectomy  is  fully 
described  and  an  attempt  made  to  give  it  a  proper  place  among  the 
various  techniques. 

If  we  can  impress  our  readers  with  the  fact  that  the  success  of 
prostatectomy  is  dependant  upon  the  proper  selection  and  preparation 
of  cases,  and  can  guide  them  to  this  attainment,  the  revision  of  this 
book  will  have  been  well  worth  while. 

About  forty  illustrations  have  been  added  which  with  the  series 
of  original  drawings  designed  for  the  former  printing  serve  to  elucidate 
the  pathological,  clinical  and  operative  phases  of  the  text. 

The  author  again  gladly  acknowledges  his  indebtedness  to  his 
co-workers  in  this  particular  field  of  study  for  their  kindness  in 
replying  to  his  questionnaire  and  for  other  courtesies  extended  to  him. 

As  on  other  occasions,  Miss.  A.  M.  Jastrow  has  again  rendered 
valuable  assistance  in  furnishing  references  and  translations  from 
foreign  literature,  as  well  as  in  the  preparation  of  hospital  statistics. 
Grateful  acknowledgement  is  tendered  to  Dr.  A.  D.  Whiting  for  the 
preparation  of  the  index. 


PREFACE  TO  THE  FIRST  EDITION 


The  surgery  of  the  prostrate  gland  has  acquired  within  the  last  few 
years  such  a  conspicuous  position  in  both  surgical  literature  and 
practice,  that  the  publication  of  another  text-book  on  the  subject  can 
scarcely  be  a  matter  of  surprise.  And  as  the  author  has  had  consider- 
able experience,  both  operative  and  otherwise,  with  prostatics,  it  was 
not  unwillingly  that  he  complied  with  the  request  of  his  publishers  to 
write  a  monograph  on  this  subject. 

In  preparing  this  volume,  the  aim  has  been  to  produce  a  work  fully 
representative  of  the  subject  of  which  it  treats.  While  the  results  of 
the  author's  own  experience  have  been  included,  he  has  taken  pains 
not  to  remain  uninformed  of  the  opinions  of  other  surgeons.  A  con- 
scientious search  and  study  of  prostatic  literature  has  therefore  been 
made,  to  the  end  that  no  personal  bias  should  infect  the  principles  of 
diagnosis  and  treatment  which  it  has  been  endeavoured  to  inculcate. 
The  present  work,  therefore,  claims  to  be  more  than  a  mere  compilation 
of  the  ideas  of  others;  the  author  has  not  hesitated  to  hold  his  own 
opinions  when  these  have  seemed  preferable,  and  he  has  tried  to 
present  the  reasons  for  these  opinions  in  such  a  way  as  to  command  the 
attention  which  he  thinks  they  deserve. 

The  illustrations  have  been  chosen  with  great  care.  They  are  in 
most  cases  original,  but  where  it  proved  impossible  to  obtain  material, 
selection  has  been  made  of  those  which  most  nearly  presented  the 
requisite  characteristics.  Although  an  attempt  has  been  made — and, 
the  author  ventures  to  think,  not  without  success — to  illustrate  every 
important  phase  of  prostatic  surgery,  both  pathological  and  clinical,  as 
well  as  operative,  yet  in  no  instance  has  a  plate  been  introduced  which 
was  not  considered  illustrative  of  the  text.  All  the  illustrations  have 
been  drawn  by  Mr.  C.  F.  Bauer,  except  the  microscopical  plates,  which 
were  prepared  by  Mrs.  J.  D.  Z.  Chase,  under  the  direction  of  Dr. 
A.  O.  J.  Kelly. 

The  treatment,  other  than  operative,  has  been  discussed  in  greater  ' 
detail  than  may  seem  warranted  to  some;  but  realizing  that  this  forms 
by  far  the  largest  part  of  actual  practice,  it  has  seemed  wise  to  the 
author  to  consider  it  at  length. 


xii    ^  Preface 

In  concluding  a  work  which  has  occupied  much  of  his  time  for  over 
a  year,  the  author  desires  to  express  a  hope  that  the  volume  will  prove 
of  real  value  to  those  surgeons  and  family  physicians  who  have  pros- 
tatics  under  their  care,  and  will  serve  in  some  little  degree  to  elucidate 
the  principles  of  surgical  treatment  of  one  of  the  most  distressing 
maladies  of  mankind. 
1634  Walnut  Street, 


CONTENTS 

Page 

Chapter  I i 

History. 
Chapter  II 17 

Embryology;    Comparative    Anatomy;    Gross    and    Microscopical    Anatomy; 
Applied  Anatomy. 
Chapter  III 61 

Physiology. 
Chapter  IV 72 

Etiology  and  Predetermining  Causes,  in  Benign  Hypertrophy  of  the  Prostute. 
Chapter  V 84 

Pathology;  Gross  and  Microscopic. 
Chapter  VI 105 

Clinical  Pathology;  Effects  on  Urethra,  Bladder,  Kidneys,  Urine  and  Rectum. 
Chapter  VII 123 

Symptoms;  Subjective  and  Objective. 
Chapter  VIII 136 

Diagnosis;  Differential  Diagnosis;  Cystoscopic  Diagnosis,  and  Functional  Studies 
of  the  Kidneys. 
Chapter  IX 171 

Prognosis. 
Chapter  X 190 

Treatment;    Constitutional;    Catheterism;  Prevention  of  Complications;  Treat- 
ment of  Complications. 
Chapter  XI 230 

Local  Palliative  Treatment;  Urinary  Fistula;  Gibson's  Operation;  Intra-urethral 
Operations;  Perineal  Galvano-Prostatotomy  (Chetwood;. 
Chapter  XII 259 

Indications  for  Radical  Treatment  by  Suprapubic  and  by  Perineal  Prostatectomy. 
Chapter  XIII 271 

Technique  of  Operations,  Including  the  Preparation  of  the  Patient  and  the  After- 
treatment. 
General  Index 347 


ENLARGEMENT  OF  THE  PROSTATE 


CHAPTER  I 
fflSTORY 


It  is  a  remarkable  thing  that  any  part  of  the  human  body  liable  to 
such  important  pathological  changes  as  the  prostate  gland  should  have 
acquired  a  conspicuous  place  in  surgery  within  such  comparatively 
recent  years.  Its  very  existence  was  unknown  until  the  beginning  of 
the  sixteenth  century,  and  it  is  only  within  the  last  twenty-five  years 
that  its  operative  surgery  has  been  deemed  of  sufiicient  magnitude  to 
require  exposition  in  monographs  of  any  size. 

The  symptoms  of  prostatism,  if  we  may  believe  Sir  Everard  Home, 
have  been  recognized  from  time  immemorial.  This  ingenious  author 
surmised  that  the  enlargement  of  the  prostate  gland  met  with  so  univer- 
sally in  old  age  is  "alluded  to  in  the  beautiful  description  of  the  natural 
decay  of  the  body,  in  the  Bible,  in  the  book  of  Ecclesiastes,  the  12th 
chapter,  the  6th  verse,  where  it  is  written,  'or  the  pitcher  be  broken  at 
the  fountain,  or  the  wheel  broken  at  the  cistern,'  expressive  of  the  two 
principal  effects  of  this  disease,  the  involuntary  passing  of  the  urine, 
and  the  total  stoppage." 

From  scattered  observations  among  the  works  of  the  classic  authors 
it  appears  that  these  writers  considered  that  patients  with  prostatic 
hypertrophy  suffered  from  "excrescences"  or  " carnosities "  at  the  neck 
of  the  bladder;  and  that  when  these  outgrowths  offered  obstruction  to 
the  evacuation  of  the  bladder,  their  destruction  was  attempted  with 
metallic  instruments,  introduced,  of  course,  through  the  penile  urethra. 
Certain  of  the  ancient  authors  recommended  incision  of  the  neck  of  the 
bladder  through  the  perineum  in  patients  with  retention  of  urine  who 
were  * '  nearly  dying  with  the  pain, ' '  when  the  urethra  was  much  inflamed, 
and  therefore  impassable  to  the  catheter,  even  if  no  calculus  existed  to 
serve  as  an  excuse  for  lithotomy;  but  it  is  not  known  that  they  actually 
performed  such  an  operation. 

The  ignorance  of  the  ancients  as  to  the  anatomical  existence  of  the 
prostate  may  be  explained  on  the  hypothesis  that  they  did  not  practise 


2  History 

dissection  of  the  human  body.  According  to  Galen,  Herophilus  first 
employed  the  term  "prostate,"  which  he,  however,  appears  to  have 
applied  to  the  seminal  vesicles  (aSevoeiSels  TpoaTarai,  "prostatae  glandu- 
losae"),  while  the  term  x^pcoetSets  irpoaTOLTaL,  "prostatas  cirsoides," 
appears  to  have  represented  the  ampullae  of  the  vasa  deferentia.  It 
should  be  recalled,  to  excuse  Herophilus  for  his  apparent  confusion  of 
terms,  that  the  prostate  gland  of  the  lower  domestic  animals,  as  well  as 
that  of  monkeys,  is  a  bifid  organ,  much  resembling  in  some  cases  the 
human  seminal  vesicles. 

Except  for  this  brief  reference,  no  mention  whatever  of  the  prostate 
gland  is  to  be  found  until  the  sixteenth  century.  Its  discovery  is 
attributed  to  Nicolo  Massa,  a  Venetian  physician,  who  died  in  1563. 
Riolanus,  about  the  middle  of  the  sixteenth  century,  was  the  first  to 
suggest  that  the  bladder  could  be  obstructed  by  a  swelling  of  the 
prostate.  In  several  cases  of  urinary  retention  this  surgeon  successfully 
practised  incision  of  the  neck  of  the  bladder  through  the  perineum,  but 
it  is  not  recorded  whether  the  cause  of  the  retention  was  enlargement 
of  the  prostate  gland. 

John  Hunter,  Sir  Everard  Home,  Brodie  and  others,  both  recom- 
mended and  practised  tunneling  of  the  obstructing  body  by  the  catheter; 
but  this  remedy  was  finally  abandoned  as  dangerous.  Chopart  records 
that  when  Astruc,  ten  years  before  his  death,  which  occurred  in  1766, 
was  attacked  by  retention  of  urine,  his  attendant,  Lafaye,  attempted 
to  introduce  a  catheter,  but  met  with  an  obstruction  from  a  tumor 
in  the  neck  of  the  bladder.  He  therefore  perforated  this  with  a  lance- 
shaped  stylet  introduced  through  the  catheter,  which  was  open  at  the 
end;  and  by  this  means  succeeded  in  forcing  the  catheter  into  the  bladder 
and  drawing  off  the  urine.  The  catheter  was  retained  fifteen  days. 
This  false  passage  through  the  obstructing  body  persisted,  and  a  cath- 
eter was  introduced  by  it  as  occasion  required  through  the  remaining 
ten  years  of  Astruc's  life;  and  the  condition  of  the  parts  as  described 
was  finally  confirmed  by  the  post-mortem  examination.  Chopart 
himself  tried  tunneling  of  the  prostate  several  times,  but  with  fatal 
results.  Billroth's  experience  was  likewise  disastrous  in  the  only  case 
in  which  he  used  forced  catheterization. 

Systematic  compression  to  maintain  a  patulous  urethra  was  first 
proposed  by  Physick,  of  Philadelphia.  His  method  consisted  in  the 
introduction  of  an  elastic  hollow  tube  through  the  compressed  prostatic 
urethra,  as  a  catheter,  and  then  its  distention  by  fluid  pressure.  Some 
success  attended  this  remedy;  and  it  was  repeated  every  two  or  three 


Compression  of  the  Urethra  3 

days,  the  pressure  being  applied  for  as  long  a  time  as  the  patient  could 
endure,  usually  from  five  to  fifteen  minutes.  Leroy  d'EtioUes  and 
Mercier  also  made  use  of  compression,  in  an  effort  to  reduce  the  size 
of  the  prostate,  or  at  least  to  mould  it  in  its  growth.     Their  plan 


Fig.  I. — Tunneling    the    Prostate.    A  False   Passage  has  been   Made   in  the 
Dilated   Prostatic  Urethra. — (Crureilhier.) 


consisted  in  introducing  a  flexible  catheter,  and  then  plunging  into  it  a 
straight  stylet,  which  forcibly  overcame  the  natural  subpubic  curve 
of  the  urethra.  Special  instruments  were  designed  for  this  purpose; 
but  the  remedy  was  so  extremely  painful  in  its  application  that  it  met 
with  little  general  favor.     The  contemporary  English  surgeons,  more- 


4  History 

over,  contended,  and  apparently  with  an  element  of  truth,  that  no 
more  was  thus  accomplished  than  by  passing  an  ordinary  steel  sound 
through  the  urethra  until  its  curved  extremity  was  wholly  within  the 
bladder,  when  its  straight  staff  would  tend  to  depress  the  internal 
orifice  of  the  urethra  to  its  normal  position.  But  probably  the  best- 
known  advocate  of  systematic  compression  was  Mr.  Reginald  Harri- 
son, of  London.  This  surgeon,  in  1881,  devised  special  olivary 
bougies,  of  gum  elastic,  from  two  to  four  inches  longer  in  the  stem  than 
the  ordinary  instruments,  and  having  an  expanded  portion  an  inch 


Fig.  2. — Mercier's  Prostatotome  and  Prostatectome. 


from  the  tip,  which  was  made  to  enter  the  bladder.     By  this  means  the 
olivary  swelling  caused  dilatation  of  the  urethra  and  compression  of 
the  prostate  both  as  the  instrument  was  introduced  into  the  bladder 
and  again  as  it  was  withdrawn,  it  being  allowed  to  remain  in  place  for 
several  minutes. 

As  is  the  case  with  every  other  department  of  surgery,  operative 
treatment  was  at  first  undertaken  only  in  emergency  cases    where 
retention  of  urine  existed;  or  incidentally  as  part  of  another  operation 
such  as  lithotomy. 

Perineal  operations  came  into  favor  earlier  than  those  by  the 
suprapubic  route,  owing  probably  to  the  greater  famiHarity  of  surgeons 
with  operations  in  the  former  region,  due  to  the  then  widespread 


Perineal   Operations  c 

practice  of  perineal  lithotomy.  Covillard  in  1 639  successfully  operated 
by  perineal  cystotomy,  and  removed  a  hard  mass,  not  a  stone,  crush- 
ing and  destroying  it  during  extraction  with  the  forceps.  This 
was  an  isolated  case,  not  undertaken  for  urinary  retention,  and  does 
not  represent  the  usual  practice  at  that  date.  Sir  Henry  Thompson 
in  referring  to  this  case,  asserts  that  the  "hard  mass"  was  a  true  tumor 
of  the  bladder;  but  Gouley  seems  to  have  considered  it  prostatic. 

Chopart  describes  how  Desault,  who  died  in  1795,  found  and 
twisted  off  a  tumor  in  the  bladder,  after  removing  a  calculus  by  peri- 
neal lithotomy;  and  Sir  William  Blizzard  several  times  before  1806 
performed  perineal  prostatotomy  for  enlargement  without  any  cal- 
culous formation.  It  has  been  denied  by  some  writers  that  Sir  William 
Blizzard's  operations  were  anything  more  than  the  opening  of  prostatic 
abscesses;  but  he  distinctly  says  that  his  object  in  performing  such  an 
operation  was  to  reduce  the  size  of  the  gland  by  incision,  irrespective 
of  the  presence  of  pus,  which  he  says  may  have  been  absorbed,  only 
induration  remaining. 

Perineal  prostatotomy  combined  with  lithotomy  was  by  no  means 
infrequent  in  the  early  part  of  the  nineteenth  century,  and  was 
sanctioned  by  Sir  William  Fergusson,  who  employed  this  procedure 
before  1848. 

Amussat  removed  a  calculus  and  a  protruding  mass  of  the  pros- 
tate by  suprapubic  cystotomy  before  1832. 

But  the  first  regular  surgical  procedure  was  established  in  1834  by 
Guthrie,  under  the  name  of  "division  of  the  bar  at  the  neck  of  the 
bladder,"  this  bar  in  some  cases  being  produced  in  his  opinion  by  a 
fold  of  mucous  membrane  stretched  taut  across  the  vesical  orifice  of 
the  urethra  by  symmetrical  enlargement  of  the  two  lateral  lobes  of  the 
prostate.  He  accomplished  his  purpose  by  a  catheter  carrying  a 
concealed  blade.  Where  marked  prostatic  enlargement  coexisted,  he 
advised  perineal  prostatotomy,  but  it  is  not  certain  that  he  ever  per- 
formed it.  Mercier,  whose  name  is  pre-eminent  in  the  early  days  of 
prostatic  surgery,  devised  in  1837  special  instruments — called  by 
Gouley  "prostatotome"  and  "prostatectome" — and  at  later  dates 
modified  them  in  various  ways.  These  instruments  resemble  the 
punch  devised  by  Young;  the  principles  governing  their  use  being 
quite  the  same.  Leroy  d'Etiolles  as  well  as  Civiale  claimed  priority 
over  Mercier  in  the  invention  of  instruments  for  the  operation 
(urethral  prostatotomy)  since  known  by  the  latter 's  name;  but  it 
appears  that  their  claims  are  ill  founded.     Indeed,  so  occupied  were 


6  History 

they  with  one  another's  claims  that  they  seem  to  have  at  times  entirely 
overlooked  the  fact  that  Guthrie  was  the  originator  of  the  method. 

A  further  improvement  on  Mercier's  method  was  that  intro- 
duced about  1873  by  Bottini,  then  of  Pavia,  who  aimed  to  avoid  the 
hemorrhage  attendant  upon  Mercier's  operation  by  the  use  of  a 
galvano-caustic  incisor,  Gouley,  however,  who  had  considerable 
personal  experience  with  Mercier's  method,  which  he  nevertheless 
preferred  to  apply  through  an  external  urethrotomy  wound,  asserted 
that  the  bleeding  was  trifling,  and  that  therefore  Bottini's  modification 
was  unnecessary.  Although  the  Bottini  operation  was  enthusiasti- 
cally practised  by  its  originator  and  a  few  other  Italian  surgeons  during 
the  twenty  years  or  more  following  his  first  description  of  it,  yet  it  by 
no  means  met  with  general  favor  until  after  the  publication  in  1897  of 
the  well-known  paper  by  Freudenberg,  who  introduced  many  improve- 
ments in  the  requisite  apparatus.  This  surgeon,  four  years  later 
recommended  the  addition  of  a  centimeter  scale  to  the  shaft  of  the 
Bottini  cautery,  in  order  that  the  operator  might  have  a  more  definite 
idea  of  the  position  of  the  beak  of  the  instrument  when  in  use.  Further 
modifications  of  the  galvano-caustic  apparatus  were  introduced  by  Dr. 
H.  H.  Young,  of  the  Johns  Hopkins  University,  the  greatest  advantage 
being  that  the  slipping  away  of  the  prostate  from  the  beak  of  the  in- 
strument was  rendered  nearly  impossible,  and  that  thus  the  risk  of 
burning  through  the  bladder  wall  instead  of  through  the  hypertrophied 
gland  was  minimized. 

In  America  Dr.  Willy  Meyer,  of  New  York,  and  Dr.  Orville 
Horwitz,  of  Philadelphia,  were  among  the  most  prominent  advocates 
of  the  Bottini  method  to  the  practical  exclusion  of  all  others. 

Belfield  in  1886  advocated  the  employment  of  Bottini's  method 
through  a  perineal  wound.  His  advice  has  been  reiterated  by  Watson 
(1888),  Keyes,  Jr.  (1902),  Wishard,  Chetwood  (1902);  while  Watson, 
(1888),  Bangs  (1898),  and  Bouffleur  (1902)  also  recommended  the 
the  employment  of  a  cautery  through  a  suprapubic  opening.  Chet- 
wood's  modified  galvano-caustic  incisor  is  used  by  some  surgeons  at 
the  present  time  in  the  treatment  of  contractures  at  the  vesical  neck; 
this  method  is  described  in  the  chapter  devoted  to  the  local  palliative 
treatment  of  prostatism. 

Meanwhile  various  other  methods  of  treatment  had  been  intro- 
duced. Of  these,  the  most  important  are  those  that  arose  from  the 
practice  of  tapping  the  bladder  in  cases  of  retention  of  urine  where 
passage  of  the  catheter  proved  impossible.     Simple  catheterization  to 


Puncture  of  the  Bladder  7 

relieve  the  bladder  of  its  residual  urine  had  long  been  employed;  Home 
had  even  used  continuous  catheterization — for  periods  of  from  one  to 
three  months — for  the  relief  of  the  cystitis.  It  is  interesting  to  note 
that  the  clever  maneuver  of  increasing  the  curve  of  the  catheter  by 
partially  withdrawing  the  stylet  as  its  beak  approached  the  obstruc- 
tion was  practised  and  taught  by  Physick,  the  Father  of  American 
Surgery,  long  before  it  was  accidentally  discovered  by  Mr.  Hey. 
Dorsey  figures  in  his  "Surgery,"  published  in  1818,  a  catheter  with  the 
well-known  prostatic  curve,  which  is  in  this  case  exaggerated,  and,  as 
Dorsey  says,  is  probably  as  great  as  will  be  found  necessary  in  any 
case  of  enlargement  of  the  prostate.  The  instrument  known  as  the 
"elbowed  catheter"  of  Mercier,  originally  of  silver,  and  devised  by  him 
as  a  modification  of  the  stone  searcher,  is  now  usually  made  of  webbing, 
and  has  been  found  most  useful  in  gaining  access  to  a  bladder  with 
prostatic  obstruction  by  the  facility  with  which  its  point  rides  over  the 
projection  at  the  vesical  orifice  of  the  urethra. 

Where  it  was  found  impossible  to  introduce  the  catheter,  the 
bladder  was  punctured,  either  suprapubically  or  through  the  rectum. 
Perineal  puncture,  though  practised  during  the  seventeenth  and  eight- 
eenth centuries,  fell  into  disuse  during  the  early  part  of  the  nineteenth, 
the  rectal  being  then  the  favorite  route.  Suprapubic  cystotomy  for 
urinary  retention  is  an  operation  over  three  hundred  years  old,  having 
been  advocated  by  Rossetus  in  1590;  but  it  was  feared  by  most  sur- 
geons, in  the  early  part  of  the  nineteenth  century,  that  in  employing 
suprapubic  puncture  there  would  be  great  danger  of  urinary  infiltration 
among  the  layers  of  the  abdominal  wall;  and  since  it  was  found  that  in 
many  instances,  even  after  the  cannula  was  withdrawn,  the  rectal 
puncture  served  fairly  well  for  micturition  until  the  urethra  again 
became  patulous  through  the  subsidence  of  inflammation,  this  was  the 
operation  usually  adopted.  Toward  the  middle  of  the  last  century 
some  surgeons  returned  to  the  suprapubic  route,  while  others  con- 
sidered a  perineal  puncture  the  only  sensible  treatment;  and  rectal 
puncture  was  almost  wholly  cast  aside. 

From  these  various  procedures  arose  finally  a  new  method  of 
treatment — that  by  urinary  fistula;  and  from  the  concomitant  drainage 
of  the  bladder  it  may  be  considered  a  distinct  advance  in  therapeusis. 
Needless  to  say,  some  of  the  patients  treated  as  above  described,  by 
puncture  of  the  bladder  for  retention  of  urine,  developed  fistulous 
tracts  which  failed  to  heal.  Thus  Parrish  records  that  a  patient  whose 
bladder  had  been  tapped  suprapubically  for  prostatic  retention  by  Dr. 


8  History 

Wistar  (who  died  in  1818)  wore  a  gold  tube  in  the  fistula  for  two  years; 
at  the  end  of  this  time  normal  urination  through  the  penis  returned, 
and  the  tube  was  discarded,  with  the  result  that  death  soon  followed 
from  a  recrudescence  of  the  bladder  troubles.  This  operation  had  been 
done,  like  innumerable  others,  for  prostatic  retention  where  the 
urethra  was  impassable;  and  Sir  Henry  Thompson  narrates  that  he 
saw  some  patients  of  Mr.  Thomas  Paget,  who  had  had  their 
bladders  punctured  suprapubically,  completely  relieved  of  the  tenes- 
mus and  other  distressing  features  by  wearing  a  cannula  or  a  catheter 
in  the  suprapubic  fistula;  and  that  this  sight  gave  him  encouragement 
to  try  the  effect  of  permanent  drainage  even  in  patients  where  retention 
of  urine  was  not  complete,  and  where  the  urethra  was  still  open  to 
instrumentation.  When  a  suitable  case  presented  itself,  he  accord- 
ingly introduced  through  the  urethra  a  long  curved  metal  catheter, 
whose  point  was  closed  by  a  conical  obturator;  and,  making  this  point 
impinge  upon  the  wall  of  the  bladder  above  the  pubic  symphysis,  cut 
down  upon  it  with  a  small  incision.  He  then  caused  the  catheter  to 
protrude  through  the  suprapubic  wound,  withdrew  the  obturator, 
passed  a  cannula  like  a  tracheotomy  tube  into  the  point  of  the  catheter, 
and  by  withdrawing  this  latter  through  the  penile  urethra,  left  the 
suprapubic  tube  in  the  bladder.  Sir  Henry  Thompson's  observations 
were  first  published  in  1875,  and  in  many  cases  in  which  he  employed 
this  method  the  relief  afforded  was  marked,  but  he  later  abandoned 
this  plan  of  treatment  for  drainage  through  the  perineum.  Dittel, 
Keyes,  and  Swinford  Edwards  were  among  the  other  surgeons  who  at 
one  time  or  another  recommended  the  suprapubic  fistula. 

An  important  improvement  in  the  method  of  forming  the  supra- 
pubic fistula  was  that  introduced  in  1888  by  Hunter  McGuire.  He 
formed  an  artificial  urethra  in  the  hypogastric  region  by  establishing 
a  fistulous  tract  upward  from  the  bladder,  so  that  the  fistula  "bore  the 
same  relation  to  the  bladder  that  the  spout  of  a  coffee  pot  does  to  the 
bowl."  By  this  procedure  McGuire  was  able  to  completely  relieve 
his  patients  of  their  cystitis  and  residual  urine,  no  involuntary  leakage 
occurring  even  in  the  supine  position,  and  the  patients  in  some  in- 
stances being  able  to  project  the  stream  of  urine  in  a  parabolic  curve 
to  a  distance  of  several  feet  by  voluntary  contraction  of  the  bladder. 
The  urine  was  retained  for  from  two  to  six  hours.  Morris,  of  New 
York,  in  one  instance  clothed  the  fistulous  tract  with  skin  by  trans- 
ferring narrow  cutaneous  flaps  into  the  wound  at  the  time  of  operation. 
Poncet  and  Delore  have  exhaustively  studied  the  subject  of  supra- 


Urinary    Fistula  q 

pubic  fistula  as  a  means  of  treatment  for  patients  with  enlarged 
prostate;  and  the  reader  is  referred  to  their  work  for  further  infor- 
mation. It  is  interesting  to  note  that  Delore  collected  three  cases 
where  patients  who  had  had  urachal  fistulas  in  childhood  had  these 
open  again  spontaneously  when  in  old  age  they  developed  prostatic 
retention.  A  complete  review  of  the  literature  on  urachal  fistula  will 
be  found  in  Cullen's  book,  "The  Umbilicus  and  its  Diseases,"  Phila- 
delphia, 1916. 

The  treatment  by  perineal  fistula  developed  as  a  natural  con- 
sequence of  puncture  by  the  perineum,  and  from  the  practice  of 
perineal  cystotomy  for  calculus  complicated  by  enlarged  prostate. 
Besides  the  mere  cystotomy,  it  was  customary  to  do  a  prostatotomy, 
and  even  a  digital  divulsion  of  the  obstructing  organ.  The  establish- 
ment of  a  perineal  fistula  with  perineal  prostatotomy  was  a  method 
largely  employed  by  Reginald  Harrison,  commencing  in  1881,  his  first 
operation  having  been  performed  on  November  4th  of  that  year.  He 
used  a  small  perineal  incision,  opening  the  membranous  urethra;  then 
the  prostate  was  incised;  and  a  metallic  perineal  tube  introduced  and 
retained  for  from  six  to  twelve  weeks.  If  the  natural  channel  was 
not  eventually  restored,  the  fistula  persisted.  Prof.  Gouley,  of  New 
York,  claimed  priority  over  Harrison  in  the  re-introduction  of  perineal 
prostatotomy,  his  first  operation — in  w^hich,  however,  he  left  no  instru- 
ment in  the  bladder — having  been  performed  April  27,  1880;  and  his 
third  operation,  in  which  he  left  a  large-sized  rubber  tube  in  the  peri- 
neal wound,  having  been  done  in  January,  188 1.  Whitehead  and 
Braun  were  likewise  among  the  earlier  advocates  of  the  treatment  by 
a  more  or  less  permanent  perineal  opening. 

Various  other  methods  of  treatment,  supported  by  different  sur- 
geons, have,  at  one  time  or  another,  claimed  the  attention  of  the 
profession.  Heine  recommended  the  injection  of  iodine  into  the 
prostate,  and  Langenbeck  and  Iversen  the  subcutaneous  use  of  ergo- 
tine,  in  the  hope  of  causing  a  reduction  in  the  size  of  the  gland.  The 
parenchymatous  injections  were  given  through  the  rectum,  but  in 
some  cases  treated  by  Heine's  method  it  was  found  that  suppuration 
and  even  death  followed,  so  that  this  practice  was  never  very  generally 
employed.  Electricity  has  been  employed  in  these  cases,  and  at  times 
with  a  certain  measure  of  success;  although  the  cases  so  reported  are 
open  to  the  criticism  of  having  possibly  been  merely  those  of  chronic 
prostatitis,  and  not  of  true  enlargement.  This  method  has  been 
carefully  studied  by  Cheron  and  Moreau-Wolf,  to  whose  excellent 
monograph  the  reader  is  referred. 


lo  History 

Excision  of  the  obstructing  parts  of  the  enlarged  prostate  by  supra- 
pubic cystostomy  was  first  widely  advocated  by  McGill  of  Leeds,  in 
1887.  Before  this  date  he  had  practised  permanent  suprapubic 
drainage,  which  he  preferred  to  that  by  the  perineum.  Belfield,  in 
America,  had  done  suprapubic  prostatectomy  before  this  time,  his 
first  operation  being  in  October,  1886;  Dittel  in  1885  had  removed 
a  portion  of  an  obstructing  prostate  through  a  previously  existing 
suprapubic  fistula,  which  he  enlarged  for  the  purpose;  Trendelenburg, 
in  May,  1886,  and  Benno  Schmidt,  in  August  of  the  same  year,  had 
employed  this  route  for  removal  of  pieces  of  the  prostate;  but  to  McGill 
has  always  rightly  been  attributed  priority  in  bringing  this  procedure 
prominently  before  the  profession.  The  most  enthusiastic  supporters 
of  McGill's  operation  were  Buckstone  Brown,  Kiimmel,  Atkinson, 
Keyes,  and  Fuller. 

As  originally  practised,  this  operation  consisted  in  cutting  off, 
through  the  usual  incision  of  suprapubic  cystotomy,  by  means  of 
scissors,  or  of  rongeur  forceps,  twisting  off  with  bladder  forceps,  stran- 
gulating with  an  ecraseur  or  crushing  with  a  lithotrite,  any  projecting 
masses  of  prostatic  tissue.  It  was,  however,  in  time  extended  so  that 
portions  of  tissue,  forming  the  so-called  prostatic  tumors,  were  enu- 
cleated with  the  finger,  either  alone,  or  aided  by  the  scissors  or  other 
instrument,  from  their  position  deep  within  the  gland. 

Many  surgeons  have  labored  to  prove  that  Freyer's  operation  intro- 
duced in  1 901,  is  not  only  surgically,  but  even  anatomically  impossible, 
assailing  Mr.  Freyer's  claim  to  originality,  and  asserting  that  he  is  labor- 
ing under  a  grave  misapprehension  if  he  thinks  he  is  the  first  person  to 
have  operated  in  this  manner;  insisting  that  his  method  is  nothing  more 
than  the  removal  of  very  large  prostatic  tumors  from  the  substance  of  the 
gland,  leaving  behind  the  outer  margin  of  glandular  tissue  which  by  the 
growth  of  these  tumors  has  been  compressed  into  a  thin  capsule-like  layer. 
Thus  Wallace  says:  "The  more  rapidly  growing  areas  (of  the  diseased 
prostate)  increase  at  the  expense  of  the  more  slowly  growing  ones,  which 
are  compressed  and  stretched  over  the  surface  of  their  quickly  growing 
neighbors.  By  this  process  a  capsule  is  formed,  ill-defined  at  first, 
but  later  becoming  more  distinct.  The  elements  forming  this  capsule 
show  in  process  of  time  a  lamellar  disposition.  The  adenomatous  mass 
can  now  be  easily  enucleated,  and  not  only  presents  a  smooth  surface, 
but  also  leaves  behind  a  smooth  cavity."  One  "capsule"  which  he 
describes,  left  behind  after  the  post-mortem  removal  of  the  prostate, 
showed  within  its  layers  a  small  lenticular  focus  of  glandular  tissue. 


Suprapubic   Prostatectomy  ii 

He  therefore  concludes:  "These  facts  .  .  .  seem  to  leave  no  reasonable 
doubt  that  the  so-called  total  prostatectomy  is  nothing  more  than  the 
removal  of  adenomatous  masses."  Yet  he  admits  that  "if  during  Hfe 
the  urethra  had  been  sacrificed,  and  the  whole  central  mass  removed, 
the  operator  would  have  been  justified  in  beheving  that  he  had  removed 
the  entire  organ;  certainly  nothing  recognizable  as  prostate  would  have 
been  left  behind."  Taylor  entirely  concurs  in  the  opinion  above 
expressed  by  Wallace,  to  the  effect  that  total  enucleation  of  the  prostate 
gland  is  an  impossible  operation;  but  Roberts,  as  the  result  of  a  careful 
examination  of  the  structures  left  after  a  post-mortem  enucleation  of 
the  prostate  gland  by  Freyer's  method,  is  of  the  opinion  that  the  whole 
gland  can  be  removed  during  life,  since  in  his  experience  just  alluded  to 
no  trace  of  prostatic  tissue  could  be  found  remaining  behind.  The 
studies  of  J.  W.  Thompson  Walker  confirm  the  opinion  of  Roberts. 

It  seems  a  pity  that  so  many  controversies  in  regard  to  surgical 
priority  are  so  constantly  arising,  and  it  appears  that  prostatic  surgery 
is  particularly  unfortunate  in  this  respect.  Riolanus  bitterly  denounced 
his  contemporaries  for  claiming  as  their  own  operations  which  had  been 
employed  before  their  grandfathers  were  born,  and  even  for  a  hundred 
years  before  that  time.  Mercier  asserted  that  Civiale  and  Leroy 
d'EtioUes  had  assumed  the  credit  of  operations  which  were  not  their 
own,  and,  with  that  delightful  tendency  toward  the  argumentum  ad 
hominem  characteristic  of  the  French  nationality,  added  that  Leroy 
had  also  assumed  a  name  to  which  he  had  no  right,  since  in  reality  Leroy 
was  from  Paris,  not  from  Etiolles.  Gouley  spoke  almost  venomously 
against  Mr.  Harrison;  and  we  think  Mr.  Freyer  would  be  well  able  to 
respond  to  his  critics  as  Harrison  did  to  Prof.  Gouley:  "I  see  that  Dr. 
Gouley  claims  priority  for  the  proceeding  just  described;  what  is  of 
more  importance  is  that  it  has  received  his  approval." 

The  fact  that  we  now  know  that  the  entire  prostate  is  not  removed 
by  Freyer's  operation  is  of  very  little  consequence;  who  first  performed 
such  an  operation  is  of  less.  To  Mr.  Freyer  is  undoubtedly  due  the 
credit  for  bringing  prominently  before  the  medical  world  a  plan  of 
operation  whereby  an  attempt  is  made  to  remove  the  entire  gland. 
Some  recent  writers,  among  them,  Guiteras,  claim  and  apparently  on 
the  best  of  grounds,  that  Fuller  of  New  York  was  the  first  to  do  a  "total" 
suprapubic  prostatectomy.  Guiteras  states  that  Fuller  "enucleated 
the  lobes  in  their  entirety"  for  the  first  time  in  1895.  As  an  aid  in  the 
enucleation  process.  Fuller  made  counter-pressure  with  the  fist  in  the 
perineum.     At  this  time  Guiteras  had  the  same  geni to-urinary  service 


12  History 

in  the  City  Hospital  so  that  he  was  in  a  position  to  follow  the  results 
of  Fuller's  work  very  carefully.  Guiteras  soon  saw  the  advantages  of 
exerting  counter-pressure  on  the  prostate  with  the  middle  and  forefingers 
introduced  into  the  rectum.  This  modification  of  Fuller's  operation  he 
described  in  August,  1900,  at  the  International  Medical  Congress  in 
Paris.  The  full  text  of  this  paper  is  reproduced  in  Guiteras'  book  on 
Urology.  If  the  reader  is  interested  in  the  historical  side  of  prostatic 
surgery  he  will  profit  by  reading  this  interesting  account  of  the  operation 
as  it  was  performed  by  one  of  the  pioneers  in  this  field  of  surgery. 

Prostatectomy  by  the  perineal  route  followed  close  on  the  practice 
of  perineal  prostatotomy,  and  preceded  by  a  number  of  years  McGill's 
introduction  of  the  suprapubic  method.  Employed  first  for  malignant 
disease  (by  Kiichler  in  1866,  by  Billroth  in  1867,  by  Demarquay  in  1873, 
by  Langenbeck  in  1876,  by  Spantonin  1882,  andbyLeisrink,ini883),its 
field  of  application  was  soon  broadened  so  as  to  include  benign  enlarge- 
ment. At  first,  as  in  the  parallel  case  of  the  suprapubic  operation, 
portions  only  of  the  prostate  were  removed.  Many  prominent  surgeons 
have  advocated  the  perineal  route,  including  Harrison  (1881),  Ashhurst 
(1882),  Annandale  (1888),  Zuckerkandl  (1889),  Watson  (1889),  Dittel 
(1890),  Goodfellow  (1891),  H.  Morris  (1895),  Ferguson  (1901),  Syms 
(1901),  Albarran  (1901),  Petit  (1902),  Moore  (1902),  Murphy  (1902), 
Bryson  (1902),  Young  (1903),  Senn  (1903),  and  Proust  (1903). 

The  simplest  perineal  operation  is  done  through  a  straight  median 
incision.  In  order  to  gain  more  room  some  surgeons  supplemented  the 
median  incision  by  an  oblique  cut  on  each  side  of  the  anus,  making  an  in- 
verted Y-shaped  incision;  this  method  was  advocated  by  Murphy, 
Baudet,  and  Senn;  while  Zuckerkandl  advised  a  transverse  semicircular 
incision,  making  a  flap  toward  the  rectal  aspect,  this  tube  being  sepa- 
rated from  the  anterior  structures  by  blunt  dissection.  A  similar 
though  less  extensive  skin  flap  is  employed  by  Albarran,  Proust,  and 
other  French  surgeons,  as  well  as  by  Young,  who  closely  follows  their 
technique.  Dittel  aimed  to  get  still  more  room  by  an  incision  completely 
encircling  the  right  side  of  the  anus  from  the  coccyx,  and  continued 
forward  in  the  median  line  of  the  perineum;  by  this  approach  he  was 
enabled  to  remove  a  wedge-shaped  piece  of  each  lateral  lobe.  The 
coccyx  may  be  excised  if  more  room  is  required  for  completing  the 
operation. 

The  position  used  for  these  variously  modified  operations  differed 
somewhat:  thus,  although  the  usual  lithotomy  position  sufficed  for 
most  surgeons,  many  preferred  to  have  this  much  exaggerated,  while 


Combined  Operations  13 

Proust  mounted  his  patients  on  a  sort  of  framework,  so  that  the  peri- 
neum was  completely  inverted.  Dittel  employed  either  the  right  lateral 
decubitus,  or  else  had  the  patient  placed  on  the  table  in  the  prone  posi- 
tion, with  the  thighs  hanging  vertically  downward. 

These  perineal  operations  all  differed  in  some  minor  details  of 
technique,  as  to  whether  the  urethra  was  opened  or  not,  whether  an 
attempt  was  made  to  preserve  the  ejaculatory  ducts,  and  as  to  the  special 
instruments  employed;  some  of  these  matters  will  be  discussed  in  the 
last  chapters  of  this  book;  but  for  such  as  appear  of  purely  historical 
interest  the  reader  must  consult  the  original  articles  referred  to  in  the 
appended  bibliography. 

Combined  operations,  by  the  perineal  and  suprapubic  routes,  also 
found  a  number  of  supporters.  Nicoll  (1895)  and  Alexander  (1896) 
removed  the  gland  through  the  perineum,  aiding  its  extraction  by  push- 
ing the  prostate  down  with  the  fingers  of  one  hand  introduced  into  the 
bladder  through  a  suprapubic  wound.  Bryson  (1899)  and  Guiteras 
(1901)  employed  a  perineal  operation  in  which  counterpressure  is 
afforded  by  the  fingers  introduced  through  a  suprapubic  incision  only 
into  the  space  of  Retzius;  while  another  enthusiastic  surgeon  (Syms), 
thinking  the  extraperitoneal  opening  of  an  infected  bladder  too  danger- 
ous an  operation,  proposed  freely  opening  the  peritoneal  cavity  and 
conducting  the  manipulations  for  counterpressure  through  the  unopened 
bladder-walls,  while  the  prostate  is  extracted  through  the  perineum. 
Fuller  (1895)  did  a  suprapubic  prostatectomy,  and  then  drained  by 
means  of  a  perineal  cystostomy,  completely  closing  the  suprapubic  wound 
on  the  removal  of  its  drainage  on  the  fourth  day. 

Other  operators  devised  special  instruments  by  which  to  draw 
the  prostate  down  into  the  perineal  wound  without  making  any  supra- 
pubic opening.  Murphy  employed  hooked  retractors  which  grasp  the 
gland  from  its  lower  surface;  and  Syms  used  a  special  hollow  rubber 
retractor,  introduced  into  the  bladder  through  a  perineal  incision  in 
the  membranous  urethra,  the  instrument  being  kept  in  place  by  dis- 
tending its  bulbous  extremity  with  water.  Proust  employed  a  de 
Pezzer  tractor  for  the  purpose  of  bringing  the  prostate  downward 
towards  the  perineal  floor.  This  instrument  has  been  modified  by 
Young  and  is  now  used  almost  universally  by  perineal  prostatectomists. 

A  mode  of  treatment  by  castration,  advocated  in  1893  by  J.  William 
White,  though  widely  employed  by  some  surgeons  for  several  years, 
has  long  since  been  discarded.  White  suggested  this  method  in  June, 
1893;  in  September  of  the  same  year  Ramm,  of  Christiania,  pubUshed 


14  History 

the  results  of  castration  on  two  patients,  on  whom  he  had  operated  the 
preceding  April.  Boeckmann  had  done  a  similar  operation  in  May, 
1893,  ^^d  it  appears  that  Tupper,  on  two  occasions,  in  1882  and  1886, 
had  performed  this  operation  with  the  deliberate  intention  of  relieving 
prostatic  troubles,  after  having  seen  the  effect  produced  by  the  removal 
of  the  remaining  testicle  from  a  patient  whose  first  testicle  had  been 
removed  for  other  causes.  Ssnitzin,  had  employed  this  operation  in 
1886.  Launois,  according  to  Moullin,  suggested  this  form  of  treatment 
to  Guyon  in  1884;  and  Mr.  Moullin  himself  discussed  its  advisability 
with  a  patient  in  1892. 

All  of  these  observations  were  much  antedated  by  those  of  John 
Hunter,  who,  in  experimenting  on  animals,  had  shown  that  double 
castration  in  young  animals  prevented  the  development  of  the  prostate, 
and  that  in  adult  animals  it  caused  the  fully  developed  gland  to  atrophy 
and  waste  away.  It  had,  moreover,  been  known  for  many  years  that  in 
certain  animals,  such  as  the  mole,  which  have  stated  periods  for  sexual 
intercourse,  the  prostate  is  much  diminished  in  size  during  the  intervals, 
and  hence  it  was  inferred  that  a  continuous  abeyance  of  the  sexual 
function  would  cause  atrophy  of  the  prostate  in  men.  Vasectomy  was 
suggested  by  Mears  as  a  less  severe  and  mutilating  operation.  The 
mortality  from  castration  for  enlarged  prostate  was  at  least  18  per 
cent.  (White),  taking  all  cases  together;  and  in  selected  cases  was 
reduced  only  to  about  8  per  cent.  Griffiths  and  Mansell  Moullin 
were  its  chief  advocates  in  Great  Britain. 

Ligation  of  both  internal  iliac  arteries  to  induce  ischemic  atrophy 
of  the  prostate  was  proposed  in  1893  by  Bier,  and  employed  by  him  in 
three  cases,  one  of  the  patients,  operated  on  intraperitoneally,  dying 
from  septic  peritonitis.  Of  eight  patients  subsequently  operated 
on  intraperitoneally  by  Bier,  two  died.  Willy  Meyer  practised  this 
operation  in  three  cases;  the  first  patient  recovering,  after  secondary 
hemorrhage  and  partial  gangrene  of  the  left  foot;  but  the  second  died 
apparently  of  renal  disease,  eight  days  after  the  operation;  while 
the  third  was  not  benefited  by  his  experience.  Konig  also  reported 
one  patient,  operated  on  by  another  surgeon,  in  Chicago,  no  change 
in  the  urinary  condition  being  produced.  Of  those  patients  who 
survived  (eleven  out  of  fifteen) ,  eight  are  said  to  have  had  their  bladder 
troubles  more  or  less  relieved,  while  three  received  no  benefit  whatever, 
and  four  died;  a  mortality  rate  of  over  26  per  cent.  Derjuschinsky 
investigated  this  method  of  treatment  by  conducting  experiments 
upon  dogs,  and  demonstrated  that  although  primary  decrease  of  the  size 


Castration  i  r 

of  the  prostate  occurred,  but  at  about  the  end  of  eight  months'  time 
it  had  regained  its  original  volume  by  virtue  of  the  establishment  of  the 
collateral  circulation. 

Among  the  more  important  of  the  older  monographs  which  have 
appeared  at  various  times,  treating  of  diseases  of  the  prostate  gland, 
mention  should  be  made  of  those  by  Sir  Everard  Home  (1811), 
Leroy  d'Etiolles  (1840),  Coulson  (1840),  Adams  (1851),  Hodgson 
(1856),  Thompson  (1858),  Gant  (1872),  Harrison  (1884),  Guyon  (1888), 
Rouchaud  (1888) ,  Watson  (1888) ,  Vignard  (1890) ,  MoulHn  ( 1894) ,  Poncet 
and  Delore  (1899),  Freyer  (1901),  Petit  (1902),  Socin  and  Burckhardt 
( 1 902) ,  and  Proust  ( 1 903) .  A  careful  study  of  these  works  will  well  repay 
the  efforts  of  the  student  who  is  interested  in  the  history  of  prostatic  sur- 
gery; indeed  they  contain  much  that  will  prove  of  the  greatest  practical 
value  to  the  surgeon.  In  the  bibliography  will  be  found  references  to 
those  authors,  contemporaneous  and  otherwise  who  have  made  note- 
worthy contributions  to  the  literature  of  prostatic  hypertrophy. 

REFEPENCES  (CHAPTER  l) 

Albarran:  Presse  Medicale,  1902,  No.  42,  17-24. 

Belfield:  Jour.  Amer.  Med.  Assoc,  1887,  viii,  303. 

Billroth:  Clinical  Surgery  Translation  of  New  Sydenham  Soc,  London,  1881,  p.  282. 

Bottini:  II    Galvani,    1874,  x.    La  Galvanocaustica  nella  Practica  Chirurgica,  Novara, ' 

1873,  and  Milano,  1876. 
Cheron  and  Moreau-Wolf :  Des  Services  que  peuvent  rendres  les  Courants  Continus  Con- 
stant dans  ITnflammation,  I'Engorgement  et  I'Hypertrophie  de  la  Prostate,  Paris,  1870. 
Chetwood,  C.  H. :  The  Practice  of  Urology,  1916,  New  York. 
Chopart:  Traite  de  Maladie  des  Voies  Urinaries,  Nouvelle  Ed.,  Paris,  1830,  ii,  86. 
Cullen:  The  Umbilicus  and  Its  Diseases,  Phila.,  1916. 
Delore:  Centrabl.  f.  d.  Krankh.  d.  Harn.  u.  Sexualorg.,  1899,  x,  343. 
Dittel:  Wien.  Med.  Blatt.,  1885,  viii,  270,  301. 
Fergusson,  Sir  Wm.,  Lancet,  1870,  i,  i. 
Freudenberg:  Berliner  klin.  Woch.,  1897,  No.  46,  S.  1002. 
Freyer:  British  Med.  Jour.,  1901,  ii,  125.  Ibid,  1902,  i,  249  and  ii,  245;  1492.  Ibid,  1903, 

i,  898. 
Gouley:  Trans.  Amer.  Surg.  Assoc,  1885,  iii,  179;  184;  190. 
Guiteras,  R.:  Urology,  ii,  p.  291,  New  York,  1913. 
Guthrie:  Anatomy  and  Diseases  of  the  Neck  of  the  Bladder  and  of  the  Urethra,  London, 

1834,  p.  252. 
Harrison:  The  Prevention  of  Stricture  and  of  Prostatic  Obstructions,  London,  1881. 

British  Med.  Jour.,  1881,  II,  1882. 
Home,  Sir  Everard:  Trans.  Philos.  Soc  London,  1805,  Paper  viii,  quoted  in  his  "Works," 

London,  i8ii,  i.     "Practical  Observations  on  the  Treatment  of  the  Disease  of  the 

Prostate  Gland." 
McGill:  Trans.  Clin.  Soc,  London,  1888,  xxi,  52. 
McGuire,  Hunter:  Trans.  Amer.  Surg.  Assoc,  1888,  vi,  349. 
Mears,  Trans.  Am.  Surg.  Ass.,  1893,  xi,  210. 


1 6  History 


Mercier:  Recherches  sur  le  Traitement  des  Maladies  des  Organes  Urinaires,  Paris,  1856, 

36;  213. 
Moullin,  C.  W.  M.:  Hunterian  Lectures  on  Enlargement  of  the  Prostate,  London,  1892. 
Physick:  See  Dorsey's  Surgery,  Phila.,  18x8,  ii,  161. 
Poncet  and  Delore:  Traite  de  la  Cystostomie  Sus-Pubienne  chez  les  Prostatiques,  Paris, 

1899. 
Proust:  Manuel  de  la  Prostatectomie  P6rineale  pour  Hypertrophie,  Paris,  1903. 
Ramm:  Centralbl.  f.  Chirur.,  1894,  xxi,  387. 
Rossetus,  Francessus:  YSTEPOTOMOTOKTAS  (id  est)  Caesarei  Partus  Assentes  His- 

torologica,  Parisiis,  1590.     Testea  Tractahunculo,  p.  263. 
Taylor,  Brit.  M.  J.:  1902,  i,  774. 
Thompson,  Sir  Henry:  Lancet,  1875,  i>  3- 
Wallace:  British  Med.  Jour.,  1902,  i,  764. 
White,  J.  Wm.:  Trans.  Amer.  Surg.  Ass.,  1893,  xi,  167. 
Young,  H.  H.:  Jour.  Amer.  Med.  Ass.,  1913,  Ix,  253;  ibid.;  1902,  xxxviii,  86. 


CHAPTER  II 

EMBRYOLOGY:  COMPARATIVE  ANATOMY :— GROSS  AND 
MICROSCOPICAL  ANATOMY:  APPLIED  ANATOMY 

Embryology. — It  will  be  recalled  that  the  genito-urinary  tract  is 
developed  from  three  main  sources — the  Wolffian  bodies  and  ducts, 
the  Miillerian  ducts,  and  the  allantois.  This  last  structure,  the 
earliest  of  the  three  to  be  formed,  juts  forth  in  the  second  week  from 
the  primitive  gut  near  its  posterior  extremity,  develops  forward  and 
protrudes  at  the  umbilicus,  forming  a  reservoir  for  waste  materials. 
The  allantois  in  the  human  embryo  is  never  a  free  vesicle  as  it  is  in 
the  lower  mammalian  forms.  Emerging  from  the  coelum  at  the  umbili- 
cus it  grows  into  the  body  stalk,  a  mesoblastic  structure  that  constitutes 
a  primary  and  permanent  connection  between  the  embryo  and  the 
chorion.  In  the  third  week  the  Wolffian  bodies  appear,  one  on  each 
side  of  the  body  cavity,  as  a  series  of  tubules,  caudal  to  the  region  of  the 
heart,  and  lying  approximately  at  right  angles  to  the  Wolffian  ducts  and 
in  the  long  axis  of  the  body  cavity.  The  Miillerian  ducts,  one  on  each 
side,  appear  about  the  fifth  week,  and  lie  parallel  to  the  Wolffian  ducts. 
Both  pairs  of  ducts  empty  into  that  portion  of  the  allantois  closest  to 
the  gut.  In  the  sixth  week  one  can  see  that  the  allantois  has  expanded 
slightly  between  its  points  of  departure  from  the  body  cavity  at  the 
umbilicus  and  the  point  at  which  it  receives  the  two  pairs  of  ducts — the 
Wolffian  and  the  Miillerian.  This  expanded  part  of  the  allantoic  tube 
forms  the  future  urinary  bladder,  and  growing  out  from  it  practically 
parallel  with  the  two  pairs  of  ducts,  is  now  observed  a  third  pair  of  tubes, 
these  being  the  ureters. 

The  ureters  are  primarly  formed  as  outgrowths  from  the  Wolffian 
ducts;  they  originate  from  the  latter  at  some  distance  from  their  termi- 
nation so  that  when  these  structures  are  subsequently  drawn  downward 
to  be  included  in  the  expanding  urinary  tract,  the  openings  of  the  Wolf- 
fian (ejaculatory)  ducts  occupy  a  position  distal  to  that  of  the  ureteral 
openings.  The  altered  position  of  the  allantois  into  which  the  Miillerian 
and  Wolffian  ducts  enter  is  termed  the  urogenital  sinus.  From  this 
the  entire  female  urethra  is  developed;  in  the  male  it  gives  rise  to  that 
portion  of  the  urethra  situated  between  the  internal  vesical  sphincter 

2  17 


1 8  Anatomy 

and  the  openings  of  the  ejaculatory  ducts.  The  portion  of  the  male 
urethra  situated  distal  to  the  openings  of  these  ducts  is  formed  in  con- 
junction with  the  penis  and  is,  therefore,  primarily  separate  and  dis- 
tinct from  the  portion  contributed  by  the  urogenital  sinus. 

As  is  well  known,  the  Wolffian  ducts  persist  in  the  male  and  form  the 
vasa  deferentia,  while  in  the  female  the  Miillerian  ducts  persist,  coalesc- 
ing in  their  lower  portions  to  form  the  uterus  and  the  vagina,  but  in  the 
upper  part  remaining  distinct,  and  constituting  the  Fallopian  tubes.  In 
the  male,  although  the  Miillerian  ducts  in  great  part  disappear  their 
lower  coalesced  extremity  persists,  and  is  found  in  the  adult  as  a  small 
diverticulum  from  the  prostatic  urethra,  known  variously  as  the  sinus 
pocularis,  utriculus,  uterus  masculinus  or  organ  of  Weber. 

Considerable  difference  of  opinion  exists  regarding  certain  phases 
of  the  embryological  development  of  the  prostate  gland,  although  the 
studies  of  Lowsley,  and  other  recent  investigators,  seem  to  have 
cleared  up  a  number  of  hitherto  uncertain  steps  in  the  process.  It  has 
been  the  belief  of  many  anatomists  that  the  initial  step  in  the  formation 
of  the  gland  concerns  the  development  of  its  capsule  and  the  stroma 
through  a  process  of  condensation  of  the  mesoblastic  tissue  that  sur- 
rounds the  urogenital  sinus  and  the  genital  cord.  This,  it  has  been 
held,  is  first  discernible  in  the  third  month  of  fetal  life  when  it  can  be 
recognized  as  "an  annular  mass  of  mesoblastic  tissue  that  surrounds 
the  lower  end  of  the  Wolffian  and  Miillerian  ducts  .  .  .  and  subse- 
quently becomes  differentiated  largely  into  unstriped  muscle  .  .  .  into 
this  (the  condensed  mesoblastic  tissue),  penetrate  solid  epithelial  out- 
growths, from  the  lining  of  the  urethra,  which  expand  into  branched 
cylinders  that  give  rise  to  the  prostatic  glandular  tissue.  These 
outgrowths  are  arranged  in  three  groups,  a  ventral,  an  upper  dorsal, 
and  a  lower  dorsal.  The  ventral  group  gives  rise  to  the  glandular 
tissue  in  front  of  the  urethra,  which  at  first  is  relatively  abundant,  but 
soon  suffers  reduction,  and  in  the  adult  organ  is  often  almost  wanting. 
The  dorsal  groups  produce  the  important  glands  of  the  median  and 
lateral  lobes.  For  a  time  the  latter  are  arranged  as  two  separate 
lobes,  but  afterwards  become  consolidated  by  the  capsule  and  broken 
up  by  the  invasion  of  the  fibro-muscular  septum."     (Piersol.) 

The  origin  of  the  musculature  of  the  prostate  and  of  its  stroma 
has  been  the  subject  of  wide  discussion.  Most  observers  have  held 
the  view  expresssed  by  Piersol  and  quoted  above,  namely  that  these 
structures  develop  from  a  thickening  of  the  mesoblastic  covering  of 
the  genital  cord — the  name  given  to  the  connective  tissue  contain- 


Embryology  lo 

ing  the  Wolffian  and  the  Miillerian  ducts.  Griffiths,  who  studied 
the  development  of  the  prostate  in  considerable  detail,  taught  that  no 
part  of  the  prostate  arises  from  the  genital  cord.  W.  G.  Richardson, 
from  his  more  recent  studies  is  of  the  same  opinion.  Griffith  described 
the  prostatic  tubules  as  invading  the  muscular  fasciculi'of  the  thickened 
posterior  half  of  the  external  circular  unstriped  muscle  coat  of  the 
urethra  in  this  situation,  the  invaded  portion  of  the  musculature 
contributing  the  permanent  muscle  content  of  the  prostate  gland. 

Many  of  the  observations  recently  reported  by  Lowsley  relating  to 
the  development  of  the  prostate  are  at  variance  with  the  generally 
accepted  views.  The  organ,  he  says,  "originates  from  five  groups  of 
tubules  which  begin  as  solid  epithelial  outgrowths  and  which  later  de- 
velop lumina.  These  various  groups  arise  from  the  floor  of  the 
urethra  between  the  ejaculatory  ducts  and  the  bladder,  from  each 
prostatic  furrow,  from  the  floor  of  the  urethra  outward  from  the  ejacu- 
latory ducts,  and  from  the  ventral  wall  or  roof  of  the  urethra,  and 
become  the  middle  right  and  left  lateral,  posterior"  and  anterior  lobes 
respectively." 

As  the  prostate  develops,  certain  well-defined  changes  occur  not 
only  in  the  morphology  and  structure  of  the  gland,  but  also  in  the 
relation  of  the  orifices  of  its  tubules  to  the  urethral  walls.  This  is 
already  evident  in  the  child  at  birth,  although  at  no  stage  of  develop- 
ment do  the  five  original  groups  of  tubules  lose  their  identity,  as  has 
been  well  shown  by  Lowsley  who  continues  in  his  description  as 
follows:  "The  tubules  grow,  with  few  exceptions,  back  toward  the 
bladder,  and  by  the  sixteenth  week  are  surrounded  by  developing 
muscle  fibres  which  in  later  stages  become  quite  thickly  disposed. 
In  early  stages  the  five  lobes  of  the  prostate  are  well  separated  from  one 
another  and  later  development  decreases  the  separation  between  the 
lateral  and  middle  lobes  .  .  .  although  the  independence  of  these 
lobes  is  discernible.  The  lateral  lobes  make  up  the  largest  portion  of 
the  gland.  The  posterior  lobe  lies  behind  the  ejaculatory  ducts  and 
becomes  separated  from  these  and  the  middle  and  lateral  lobes  by  a 
plane  of  connective  tissue.  The  tubules  making  up  the  anterior  lobe 
are  at  first  as  large  as  other  tubules  and  are  quite  numerous;  but  at  the 
sixteenth  week  they  are  reduced  in  size,  comparatively  speaking,  and 
after  this  time  appear  to  shrink  into  insignificance.  All  of  the 
tubules  of  the  prostate  seem  to  be  firmly  bound  together  within  its 
capsule,  with  the  exception  of  those  of  the  middle  lobe  whose  upper 
ends  in  some  cases  seem  to  extend  beyond  the  capsule,  lying  freely  be- 
tween the  vasa  deferentia  and  the  bladder." 


20 


Anatomy 


Evidently  therefore,  in  the  opinion  of  Lowsley,  the  glandular  portion 
of  the  prostate  is  derived  from  five  sets  of  tubules,  in  contradistinction 


Fig.  3. — Development  of  the  Genito-urinary  Tract  (Diagrammatic). 
I.  Body  wall.     A.  Allantoic  stalk  at  umbilicus.     B.  Urinary  bladder.     C.  Cloaca.     G. 
Primitive  gut.     S.  Symphysis  pubis.     M,  M'.  Mullerian  ducts.     W,  W.  Wolffian  bodies 
and  ducts.     U,  U'.  Ureters  with  kidneys  attached. 

to  the  views  held  by  Pallin  and  others  that  but  three  groups  of  tubules 
are  concerned  in  its  development.  The  former  seems  to  have  definitely 
established  the  independent  origin  of  the  median  lobe  tubules  which  have 


Embryology 


21 


been  looked  upon  by  Pallin,  Evatt,  Jores  and  their  followers  as 
outgrowths  from  the  lateral  lobes.  Until  comparatively  recent  times, 
all  so-called  median  lobe  obstructions  at  the  vesical  outlet  were  supposed 
to  take  origin  in  prostatic  tubules,  whereas  in  fact  the  majority  of  these 
arise  in  the  subcervical  group  of  glands  (Albarran's  tubules— subcervical 
glands),  and  are  not  of  prostatic  origin  at  all. 


Fig.  4. — FcETAL  Prostate,  with  Lower  Half  of  Bladder  Attached. 
Natural  size,  and  ten  times  natural  size.     (From  a  six  months'  foetus  in  the  Museum  of 

the  Lankenau  Hospital.) 

Sir  Everard  Home  took  credit  to  himself  for  discovering  a  third 
(middle)  lobe,  although  both  John  Hunter  and  Morgagni  had  recognized 
median  lobe  obstructions  which  may  or  may  not  have  been  of 
prostatic  origin.  Home's  observations  passed  practically  unchallenged 
among  English  surgeons,  and  enlargement  of  the  third  lobe  became  the 
most  common  pathological  change  to  which  the  prostate  gland  was 
subject.  In  France,  however,  surgeons  were  not  ready  to  acknowl- 
edge so  important  a  discovery,  as  this  seemed  to  be,  by  a  foreign  author; 
and  they  rather  grudgingly  designated  this  portion  of  the  prostate  the 


22 


Anatomy 


third  or  median  "part,"  being  unwilling  to  accord  it  the  dignity  of  a 
distinct  lobe.  Sir  Henry  Thompson,  writing  in  1858,  opened  the 
controversy  anew  by  pointing  out  that  Home's  observations  were  not 
numerous  and  that  he  had  not  found  his  third  lobe  in  every  case. 
Sir  Henry  therefore  came  to  the  conclusion  that  this  middle  lobe  was 
merely  a  pathological  formation,  and  did  not  normally  exist  at  all. 
Congenital  absence  of  the  median  tubules  does  undoubtedly  occur  but 
the  rarity  of  such  mal-development  is  shown  in  the  investigation  of 
Lowsley  who  found  only  one  among  ninety-eight  autopsy  specimens 
from  dissecting  room  cadavers  and  fetuses  with  absence  of  the  middle 


Genital  iody 
Wolffian  Ducts 
Mailerian  Ducts 


Peritoneum. 


Prostate 


(Aponeurosis 
Denonvilliers 


Fig.  5. — Development  of  the  Aponeurosis  of  Denonvilliers. — {Cuneo  and  Veaii.) 

lobe  tubules.  Home,  and  later  Griffith,  found  orifices  of  prostatic 
ducts  on  the  floor  of  the  urethra  proximal  to  the  verumontanum. 
The  secretion  which  was  emitted  from  these  orifices  on  pressure,  the 
latter  found,  came  from  glandular  tissue  situated  between  the 
urethra  and  the  ejaculatory  ducts.  This  collection  is  now  known  to 
have  an  independent  origin  from  the  remaining  tubules  of  the  prostate 
and  to  retain  this  independence  more  or  less  perfectly  throughout  life. 
It  is  the  belief  of  Tandler  and  Zuckerkandl  that  benign  prostatic  hyper- 
trophy mainly  concerns  this  group  of  tubules. 

A  further  embryological  fact  of  importance  is  the  formation  of  a 
bursa  between  the  prostate  and  the  rectum  by  the  obliteration  of  the 


Comparative  Anatomy  23 

upper  end  of  a  serous  process  extending  downward  from  the  peritoneum. 
The  fascial  walls  of  this  closed  serous  cavity  between  the  prostate  and 
the  rectum  is  widely  known  as  the  "aponeurosis  of  Denonvilliers. " 
In  the  adult,  although  separable  into  two  layers,  these  processes  of  tissue 
no  longer  enclose  a  distinct  cavity. 

Comparative  Anatomy. — All  mammals  possess  a  prostate,  but  in 
birds,  according  to  Strieker,  there  is  no  analogous  organ.  In  certain  of 
the  batrachians  he  states  that  the  pelvic  and  anal  glands  swell  up  during 
the  procreative  season,  and  discharge  their  secretion  into  the  cloaca; 
these  glands  are  supposed  to  represent  the  prostate  and  the  glands  of 
Cowper.  In  fishes  there  are  aggregations  of  acini  that  communicate 
with  the  vas  deferens  through  ducts.  Owen  states  that  insects  have 
three  pairs  of  prostates. 

Although  all  mammals  are  endowed  with  a  prostate,  yet  it  is  by 
no  means  identical  in  form  in  all.  In  some  mammals  the  prostate 
develops  around  the  lower  extremity  of  the  Wolffian  ducts,  and  when 
fully  developed  retains  its  close  relation  to  the  vasa  deferentia,  but  as 
two  distinct  glands,  and  is  not,  as  in  the  human  adult,  applied  around 
the  first  portion  of  the  urethra  embracing  the  ejaculatory  ducts  only 
incidentally.  Moullin  states  that  even  in  man  the  situation  of  the 
prostate  was  probably  originally  around  the  Wolffian  ducts,  but  that  its 
place  has  become  shifted  in  the  course  of  racial  development.  In  the 
bull,  the  buck,  and  other  of  the  ruminants,  indeed  in  almost  all  the  forms 
of  mammalian  life  below  the  human,  including  the  monkey,  the  prostate 
continues  throughout  life  a  bifid  gland.  The  close  resemblance  which  it 
bears  in  some  of  these  animals  to  the  seminal  vesicles  may  account  both 
for  the  ignorance  of  the  ancients  respecting  the  existence  of  the  human 
prostate  gland,  and  for  the  habit  of  the  earliest  of  the  modern  anatomists 
of  referrmg  to  it  as  the    "glandulae  prostatae." 

W.  G.  Richardson  has  called  attention  to  the  location  of  the  acces- 
sory glands  of  generation — the  prostates,  the  seminal  vesicles,  and  the 
Cowperian  glands — in  various  animals.  He  finds  that  the  seminal 
vesicles  are  constantly  in  relation  with  that  part  of  the  genital  tract 
developed  from  the  Wolffian  ducts,  that  the  prostates  are  placed  next, 
in  relation  with  that  part  developed  from  the  urogenital  sinus,  while  the 
glands  of  Cowper  are  furthest  away  from  the  testicles,  in  relation  with 
the  bulbous  urethra.  This  same  general  arrangement  exists  in  the 
human  being,  the  glands  of  Cowper  discharging  their  secretion  into 
the  bulbous  urethra,  the  prostate  glands  into  the  prostatic  urethra, 
and  the  seminal  vesicles  pouring  their  secretion  into  the  vasa  deferentia 


2  4  Anatomy 

before  these  latter  have  joined  the  urethra.  In  the  lower  animals  the 
accessory  genital  glands  differ  much  in  relative  size  and  importance, 
all  three  sets  not  always  being  present.  In  the  civet  cat,  for  example, 
Cowper's  glands  are  exceptionally  large,  apparently  to  compensate  for 
the  entire  absence  of  the  seminal  vesicles;  while  in  the  guinea-pig  the 
seminal  vesicles  are  of  immense  size,  and  the  glands  of  Cowper  very  in- 
significant in  comparison.  In  the  squirrel,  on  the  other  hand,  the 
Cowperian  glands  are  very  large,  and  the  seminal  vesicles  are  small. 


Fig.  6. — Testes.   Prostates,   and   Protometra   of   the   Goat. 
Below  are  seen  the  prostates.     Between  the  vasa  deferentia  is  seen  the  uterus  mas- 
culinus.  which  is  bifid;  its  two  horns  diverge  and  continue,  closely  applied  to  the  vasa 
deferenua,  as  far  as  the  epididymis  of  each  side. — {After  Owen.) 

Genitalia  of  the  goat  (Fig.  6)  approach  most  nearly  to  the  primi- 
tive or  indifferent  sexual  type.  Here  the  Mullerian  ducts  persist 
throughout  their  length,  as  well  as  the  Wolffian  ducts,  and  we  have  the 
unusual  sight  of  the  uterus  masculinus  extending  as  a  bifid  organ  from 
the  urethra  to  the  epididymis.  Nor  do  the  lower  ends  of  these  persist- 
ent Mullerian  ducts  pierce  the  prostate  to  empty  into  the  urethra;- on 
the  contrary,  the  prostate  glands,  one  on  each  side  of  the  urinary  chan- 
nel, are  far  removed  from  the  situation  of  the  uterus  masculinus,  being 
much  nearer  the  bulbous  urethra.  This  satisfactorily  disproves  the 
theory  formerly  held  by  some  that  the  prostate  gland  was  the  homologue 
of  the  female  womb. 


Comparative  Anatomy  25 

In  the  hyena  the  genitalia  (Fig.  7)  approach  more  nearly  the 
human  in  type,  but  conclusively  show  that  there  is  no  necessary  con- 


FiG.  7. — Accessory  Male  Glands  and  Protometra  of  Hy^na  Striata. 
Above  is  seen  the  bladder.  Emptying  into  the  prostatic  urethra  are  the  vasa  def- 
erentia  on  each  side  of  the  minute  uterus  masculinus  (protometra).  The  prostate  glands 
are  large,  somewhat  kidney-shaped  bodies,  in  no  way  connected  with  the  uteius  mascu- 
linus. Emptying  into  the  penile  urethra  below  are  seen  the  immense  glands  of  Cowper. 
Natural  size. — {After  Otven.) 

nection   between    the    uterus    masculinus    and    the   prostate.     The 
Cowperian  glands  of  the  hyena  are  of  extraordinary  size. 


26  Anatomy 

In  mammals  who  have  a  rutting  season  the  prostate  gland  enlarges 
noticeably  at  this  period,  and  at  its  close  again  diminishes  to  its  former 
size.  John  Hunter  studied  the  prostate  gland  in  moles,  and  found 
that  while  it  was  small  and  insignificant  during  winter — the  period  of 
quiescence — in  the  rutting  season  it  became  very  large  and  was 
filled  with  mucus.  His  observations  have  been  confirmed  by  Owen 
and  by  Griffiths.  The  last-named  author  also  studied  the  pros- 
tates of  hedgehogs,  and  found  them  to  have  the  same  characteristics. 

Such  observations  as  these,  taken  together  with  the  facts  that 
castration  in  animals  has  long  been  known  to  produce  a  certain  amount 
of  prostatic  atrophy;  that  failure  of  development  of  one  vas  deferens 
has  usually  been  found  associated  with  a  prostate  which  is  small  and  ill- 
formed  on  the  affected  side  (see  Fig.  8);  and  the  theory  of  "displace- 
ment" in  the  course  of  racial  development,  adopted  by  Mr.  Mansell 
Moullin  on  the  authority  of  Schafer;  leave  no  reasonable  doubt  that 
the  prostate  is  physiologically  a  part  of  the  genital  and  not  of  the 
urinary  apparatus. 

This  idea  may  be  further  strengthened  by  a  consideration  of  the 
ornithorhyncus,  or  duck-mole.  In  this  animal,  a  small  oviparous 
mammal  of  Australia,  the  urine  is  discharged  through  the  cloaca,  in 
common  with  fecal  matter,  as  is  the  case  in  birds;  and  the  penis 
with  its  contained  urethra  serves  solely  and  entirely  for  the  trans- 
mission of  the  semen  and  the  fluids  from  the  accessory  generative 
glands.  And  although,  unfortunately  for  the  complete  proof  of  our 
theory,  this  interesting  animal  is  not  endowed  with  a  prostate,  yet  it 
is  clear  that  were  a  prostate  present,  its  secretion  would  be  discharged 
along  with  that  coming  from  Cowper's  glands,  which,  as  well  as  the 
lower  ends  of  the  vasa  deferentia,  are  considerably  enlarged.  No  sem- 
inal vesicles  are  present  either,  but  the  enlargement  of  the  lower  ends 
of  the  vasa  deferentia  is  evidently  to  compensate  for  this  lack. 

In  connection  with  the  comparative  anatomy  of  the  prostate,  a  few 
words  in  relation  to  its  comparative  pathology  will  not  be  out  of  place. 

It  is  well  known  that  of  all  animals  the  dog  is  most  prone  to  prostatic 
enlargement.  According  to  Ciechanowski,  it  is  also  the  only  domestic 
animal  which  suffers  from  an  infectious  urethritis.  From  this  fact 
he  draws  an  argument  in  favor  of  his  theory  that  all  prostatic  over- 
growth is  due  to  an  inflammatory  change. 

In  other  animals  castration  invariably  causes  prostatic  atrophy; 
whereas  in  dogs  it  frequently  fails  to  have  any  effect,  although  it  was 
until  recently  about  the  only  method  of  treatment  applicable  for  their 


Gross  Anatomy 


27 


relief.  Perineal  prostatectomy  has  also  been  employed;  and  Loumeau 
states  that  a  veterinary  surgeon,  a  friend  of  his,  had  employed  ten  times 
successfully  an  operation  precisely  similar  to  Freyer's  suprapubic 
prostatectomy,  before  learning  from  Loumeau  that  the  same  operation 
had  been  practised  upon  man. 

Gross  Anatomy. — The  shape  of  the  prostate  is  approximately  that 
of  a  truncated  cone,  and  has  often  been  compared  to  a  Spanish  chestnut 
or  a  horse-chestnut,  having  its  apex  down  and  forward,  and  its  base 
beneath  the  urinary  bladder.  In  size,  the  gland  is  normally  about 
four  centimetres  from  base  to  apex,  a  little  larger  in  transverse  diameter, 
and  from  two  to  two  and  a  half  centimetres  in  depth  or  height.  Its 
weight  varies  from  fifteen  to  twenty-four  grammes. 

The  greatest  increase  in  the  size  of  the  gland  takes  place  during  the 
second  decade  of  life  so  that  by  the  beginning  of  the  third  decade  it 
has  reached  its  maximum  normal  development. 

The  variations  in  size  of  the  prostate  at  different  ages  have  been 
tabulated  by  Lowsley  from  a  study  of  224  specimens,  as  follows. 


Table  Showing  the  Changes  in  Size  of  the  Prostate  Gland  at  Various  Ages  in  a 
Series  of  224  Cases  (Lowsley) 


Age 

Number 

of 

cases 

Length,  centimetres 

Width,  centimetres 

Height,  centimetres 

Variations   Average 

Variations 

Average 

Variations 

Average 

I  St  Decade 
i-io  years.. . . 

38 

I . 0  to  I . 7 

1.2 

I . 0  to  2 . 0 

i-S 

0.7  to  1.3 

09 

2nd  Decade 
10-20  years.. . . 

10 

2.Sto3-5 

30 

3-8 

1 . 8  to  2 . 4 

2.1 

3rd  Decade 
20-30  years 

40 

2.8  t04.o 

3-3 

3.6  t05.2 

4.1 

2 . 0  to  3 . 0 

2.4 

4th  Decade 
30-40  years. . . . 

33 

2 . 4  to  4 . 0 

31S 

3.oto5.o 

4.1 

1 . 6  to  3 . 0 

2-55 

5th  Decade 
40-50  years 

42 

3.0  to  4.6 

3-45 

3 . 6  to  5 . 0 

4.0 

2.3103.8 

2.65 

6th  Decade 
50-60  years 

29 

2.4104.5 

3-65 

3-3  to  5.0 

4.37 

2.4103.4 

2-75 

Old  Age 
60  years 

32 

2 . 6  to  4 . 5 

3   23 

3 . 0  to  5 . 0 

4.12 

2 . 0  to  3 . 6 

2.47 

28  Anatomy 

The  prostate  consists  of  glandular  acini  and  ducts  embedded  in 
involuntary  muscle;  the  latter  supported  by  fibrous  tissue,  constituting 
the  stroma  of  the  organ.  This  stroma  forms,  by  a  peripheral  condensa- 
tion, a  capsule  for  the  gland  which  is  distinct  from  its  sheath,  the  latter 
being  derived  from  the  pelvic  fascia.  Opinions  differ  as  to  the  existence 
of  a  distinct  prostatic  capsule.  By  the  use  of  the  term  capsule,  we  do 
not  mean  to  imply  the  presence  of  a  definite  envelope  of  tissue  that 
surrounds  and  is  easily  separable  from  the  glandular  tissue  proper.  The 
true  prostatic  capsule  is  merely  the  condensed  peripheral  portion  of  the 
fibro-muscular  stroma.  This  is  intimately  blended  with  its  intraglan- 
dular  portion,  while  externally  it  is  inseparably  bound  to  the  anatomic 
capsule,  a  fibrous  connective  sheath  which  is  a  part  of  the  pelvic  fascia. 
The  capsule  referred  to  in  surgical  writings  as  surrounding  the  ade- 
nomatous or  enlarged  prostate,  is,  we  believe,  formed  in  association  with 
the  neoplasmic  process.  It  is,  therefore,  a  structure  separate  and 
distinct  from  those  described  above. 

The  fibro-muscular  stroma  comprises,  according  to  Kolischer,  from 
one-half  to  two-thirds  of  the  bulk  of  the  prostatic  gland.  Walker,  on 
the  other  hand,  believes  that  the  prostate  is  composed  of  about  three- 
fourths  glandular  substance  and  one-fourth  stroma.  Certain  other 
writers  distinguish  between  a  glandular  and  a  muscular  type  of  organ 
according  to  the  prominence  of  one  or  the  other  element  in  the  histo- 
logic picture.  In  the  majority  of  instances,  the  stroma  constitutes 
slightly  more  than  half  of  the  bulk  of  the  prostate. 

Piercing  the  prostate  from  base  to  apex,  a  little  anterior  to  its 
central  axis,  runs  the  urethra,  whose  first  part,  extending  from  the 
vesical  orifice  behind  to  the  deep  layer  of  the  triangular  ligament  in 
front,  is  called  "the  prostatic  urethra."  This  portion  of  the  urethra 
is  sometimes  spoken  of  as  the  urethral  surface  of  the  prostate  gland. 
Beyond  the  vesical  wall  which  surrounds  its  most  proximal  portion,  the 
pars  prostatica  is  entirely  surrounded  by  the  prostate  gland.  This  is 
the  most  distensible  portion  of  the  entire  urethra;  when  fully  distended 
it  is  roughly  fusiform  in  outline.  When  at  rest  its  lumen  is  effaced 
through  apposition  of  the  anterior  and  posterior  walls.  Its  lumen  is 
reduced  by  a  spindle  shaped  elevation  to  which  the  terms  caput  gallin- 
aginis,  urethral  crest,  verumontanum,  and  colliculus  seminalis  have 
been  applied.  This  structure  which  averages  2.0  cm.  in  length,  0.41 
cm.  in  width  and  0.3  cm.  in  height  extends  along  the  dorsal  wall  of  the 
prostatic  urethra  from  the  uvula  of  the  vesical  trigone  above  to  the 
membranous  urethra  below. 


Gross  Anatomy  29 

The  summit  of  the  colliculus  is  situated  at  about  the  mid-point  of 
the  prostatic  urethra,  the  lumen  of  which  appears  crescentic  in  outline 
at  this  point  in  transverse  section.  The  colliculus  exists  as  a  result  of 
an  elevation  of  the  floor  of  the  urethra  caused  by  the  ejaculatory  ducts 
and  the  presence  at  this  point  of  the  prostatic  utricle,  sinus  pocularis, 
or  uterus  masculinus,  the  various  terms  given  to  a  tubular  diverticulum 
whose  slit-like  mouth  occupies  the  forward  declivity  of  the  colliculus. 
The  mouth  of  the  utricle  which  averages  0.17  cm.  in  width  leads  into 
the  utricle  proper,  which  has  an  average  depth  of  0.5  cm.  Its  axis  is 
directed  obliquely  to  that  of  the  prostatic  urethra,  although  lying  in  the 
middle  line,  and  its  cavity  looks  forward,  so  that  a  small  catheter  or 
sound  passed  along  the  floor  of  the  urethra  may  catch  in  its  orifice.  A 
catheter  or  probe  may  be  easily  inserted  into  the  utricle  for  therapeutic 
purposes,  through  an  endoscopic  tube.  Its  -cavity  leads  upward  and 
backward  into  the  substance  of  the  prostatic  gland.  The  term  uterus 
masculinus  is  appropriately  applied  to  it  since  it  represents  the  fused 
lower  ends  of  the  Miillerian  ducts  of  the  embryo,  and  is,  therefore, 
regarded  as  the  morphological  equivalent  of  the  vagina  and  the  uterus. 
On  each  side  of  the  verumontanuni  are  found  the  orifices  of  the  ducts 
coming  from  the  prostatic  acini.  The  depressed  portions  of  the 
urethra  on  each  side  of  the  verumontanum  into  which  the  lateral  lobe 
tubules  empty,  are  known  as  the  prostatic  sinuses.  The  number  of 
prostatic  ducts  probably  varies  within  wide  limits,  being  usually  from 
fifteen  to  twenty.  The  anterior  lobe  tubules  open  on  the  roof  of  the 
urethra  at  a  point  opposite  the  verumoijtanum.  On  the  sides  of  this 
structure  and  sometimes  on  its  summit  to  the  outer  side  of  the  openings 
of  the  ejaculatory  ducts,  are  situated  the  openings  of  the  posterior 
lobe  tubules.  The  middle  lobe  empties  itself  through  ducts  which  open 
on  the  floor  of  the  urethra  between  the  internal  vesical  sphincter  and 
the  verumontanum.  The  position  of  the  prostatic  duct  openings  in 
relation  to  the  mouths  of  the  ejaculatory  ducts  insures  thorough  admix- 
ture of  the  various  constituents  of  the  seminal  fluid  at  the  time  of 
ejaculation.  Emptying  into  the  floor  of  the  prostatic  urethra,  and  con- 
sequently coursing  through  the  posterior  portion  of  the  prostate  gland, 
are  found  the  ejaculatory  ducts  of  the  vasa  deferentia  and  the  seminal 
vesicles.  The  latter  enter  the  prostate  through  a  transverse  crescentic 
cleft,  situated  at  the  junction  of  its  inferior  and  basal  surfaces,  and 
unite  within  the  substance  of  the  gland  to  form  the  ejaculatory  ducts. 
These  tubes  lie  close  together  in  their  passage  through  the  prostate,  their 
muscular  walls  blending  with  each  other  and  with  the  prostatic  stroma. 


30 


Anatomy 


The  latter  is  well  defined  in  the  region  of  the  ducts  and  serves  to  separate 
the  lateral  and  middle  lobe  tubules  from  those  composing  the  posterior 
lobe.  Thus  is  explained  the  backward  displacement  of  the  ejaculatory 
ducts  that  takes  place  in  adenomatous  enlargements  of  the  middle  and 
the  lateral  lobes. 

The  intraglandular  portions  of  the  ducts  run  anteriorly  on  a  gradual 
slant  until  they  reach  the  coUiculus,  where,  as  Porosz  has  shown,  they 


Fig.  8. — Congenital  Absence  of  the  Left  Vas  Deferens  and  Seminal  Vesicle, 
Associated  with  Imperfect  Development  of  the  Prostate  on  the  Slde  Affected.— t 
{Socin,  after  Launois.) 


bend  upward,  then  curve  downward  and  there  open  laterally  on  the 
declivity  of  the  coUiculus.  He  further  states  that  the  curve  is  often  a 
double  one,  suggesting  a  hook  bent  on  itself.  The  lumen  of  the 
terminal  part  of  each  duct  becomes  much  constricted,  and  at  this  point 
the  ducts  are  said  by  Porosz  to  have  a  complicated  sphincter  muscle 
surrounding  them  which  is  a  part  of  the  prostatic  stroma.  The  mouths 
of  the  ejaculatory  ducts  are  protected  by  small  valve-like  folds  of 
mucous  membrane  that  effectually  close  the  distal  portion  of  the  ducts 


I 


Gross  Anatomy  31 

when  distension  of  the  prostatic  urethra  occurs.  Slight  congenital 
variations  in  the  position  of  the  openings  of  the  ejaculatory  ducts  are 
common,  and  in  rare  instances  they  have  been  found  within  the  margins 
of  the  uterus  masculinus. 

The  prostate  gland  is  formed  by  the  coalescence  of  five  lobes  around 
the  urethra  although  in  adult  life  the  two  lateral  lobes  compose  the  bulk 
of  the  organ.  The  comparatively  small  portion  of  the  prostate  lying 
on  a  plane  anterior  to  the  urethra  belongs  to  the  lateral  lobes  which 
are  joined  together  in  front  of  the  urethra  by  the  anterior  commissure. 
The  anterior  lobe  tubules  undergo  early  and  often  complete  atrophy. 
The  exact  depth  in  the  prostate  at  which  the  urethra  is  found  largely 
depends  upon  the  extent  of  the  forward  growth  of  the  lateral  lobes.  In 
some  few  instances  the  urethra  merely  grooves  the  anterior  or  upper 
surface  of  the  prostate;  but  in  the  majority  of  cases  it  is  situated  with 
one-third  of  the  organ  in  front  and  two-thirds  back  of  the  urethra.  The 
wedge-shaped  part  of  the  gland  situated  between  the  floor  of  the  urethra 
and  the  ejaculatory  ducts  constitutes  the  middle  lobe,  while  that  portion 
bounded  anteriorally  by  the  ejaculatory,  laterally  by  the  median  surface 
of  the  lateral  lobes,  and  inferiorly  by  the  inferior  surface  of  the  gland 
comprises  the  posterior  lobe. 

The  inferior  or  rectal  surface  is  grooved  by  a  median  furrow  be- 
tween the  lateral  lobes;  this  marks  the  location  of  the  posterior  com- 
missure. Grossly  the  normal  adult  prostate  seems  to  consist  merely 
of  the  two  lateral  lobes  coalesced  around  the  urethra.  It  is  important 
nevertheless  to  keep  in  mind  the  location  of  the  middle  and  the 
posterior  lobe  tubules. 

The  inferior  surface  of  the  prostate  is  rather  flat,  and  rests  upon 
the  rectum.  In  addition  to  the  longitudinal  groove,  mentioned 
above,  there  is  also  a  transverse  crescentic  slit  at  the  juncture  of  the 
inferior  and  basal  surfaces.  This,  as  already  mentioned,  gives  pas- 
sage to  the  ejaculatory  ducts  which  sink  into  the  substance  of  the 
prostate. 

The  superior  surface  is  more  convex,  and  is  placed  about  two 
centimetres  or  less  behind  the  lower  part  of  the  symphysis  pubis.  The 
base  rests  against  the  "neck"  of  the  bladder,  and  the  apex  is  in  con- 
tact with  the  deep  layer  of  the  triangular  ligament  of  the  perineum. 
The  axis  of  the  prostate  makes  an  angle  of  about  45  degrees  with  the 
horizon  when  the  individual  is  in  the  erect  position. 

Sheath  of  the  Pro5to/e.— Tracing  the  transversalis  or  pelvic  fascia 
down  along  the  sides  of  the  pelvis,  we  come  to  the  white  line  of  origin 


32 


Anatomy 


of  the  levator  ani  muscle,  which  stretches  from  the  neighborhood  of 
the  pubic  symphysis  in  front  to  the  spine  of  the  ischium  behind.     At  this 


//  I;\fe1:l 


Fig.  9. — Median  Sagittal  Section  of  the  Lower  Abdomen  and  Pelvis,  showing  the 
General  Relations  of  the  Prostate  to  the  Bladder,  the  Urethra,  and  the 
Rectum. 

white  line  the  pelvic  fascia  divides  into  two  sheets,  the  inferior  or  ex- 
ternal (called  the  obturator  fascia),  passing  between  the  obturator 
internus  and  the  levator  ani,  and  later  giving  off  two  processes — one, 


Prostatic   Sheath  33 

on  the  outer  wall  of  the  ischiorectal  fossa,  encircling  the  internal 
pudic  vessels  and  nerve;  while  the  inner  layer  covers  the  inferior  or 

Bladder 


^aculator^  duct 
Rectovesical  fascia 
OShratorint 
f^/Mcbone 


jProstate 

/^ectfi?7i 

levatorAni 


/scki/im 
Gluteus  mazimuJ 
Obturator  fascia 
Int.Pudic  vessels  i^/ieroe 


I  fascia 

^Isckio-rectal fossa 

Sphincter  Ani 

Int.  Sphincter  Ant 


Fig.  ic. — Transvebse  Section  of  Pelvis,  Showing  the  General  Relations  of 
THE  Prostate  to  the  Pelvic  Walls.  Looking  J'orward  Towards  the  Symphysis 
Pubis. 

The  plane  of  section  is  nearly  horizontal  with  the  subject  in  the  erect  posture. 

external  surface  of  the  levator  ani,  and  is  called  the  anal  fascia.     The 
second  original  division  of  the  pelvic  fascia,  called  the  recto-vesical 


34  Anatomy 

fascia,  arising  at  the  white  line,  passes  over  the  superior  or  internal 
surface  of  the  levator  ani  muscle,  and  subdivides  into  three  layers: 
(i)  The  superior  layer  passes  along  toward  the  median  line,  above  the 
prostatic  plexus  of  veins,  and  over  the  upper  surface  of  the  prostate, 
and  coalesces  with  the  external  coat  of  the  bladder.  (2)  The  middle 
layer  of  the  recto-vesical  fascia  passes  below  the  prostatic  plexus  of 
veins,  beneath  the  prostate  and  bladder,  and  above  the  rectum,  and 
joins  with  its  fellow  of  the  opposite  side.  (3)  The  third  and  last  layer 
of  the  recto-vesical  fascia  hugs  the  superior  or  internal  surface  of  the 
levator  ani,  and  blends  with  the  outer  coat  of  the  rectum.  The  two 
layers  last  described  form  together  the  aponeurosis  of  Denonvilliers 
which  lies  between  the  prostate  above  and  the  rectum  below,  and  is 
really  a  serous  sac  originally  derived  from  the  peritoneum,  although 
more  conveniently  described  here  as  part  of  the  recto-vesical  fascia. 

These  three  layers  of  the  recto-vesical  fascia  are  distinguishable 
only  at  the  sides  of  and  below  the  prostate.  Toward  the  median  line 
above  they  are  not  separate,  but  form  the  pubo-prostatic  ligaments, 
intervening  between  the  most  anterior  fibres  of  the  levator  ani  muscle 
(levator  prostatas  of  Santorini)  and  the  space  of  Retzius,  and  blending 
at  the  median  line,  between  these  muscular  fibres  (where  they  contain 
the  dorsal  vein  of  the  penis) ,  with  the  fascia  on  the  outer  side  of  these 
muscles — the  deep  layer  of  the  triangular  ligament  of  the  perineum, 
which  is  itself  a  prolongation  of  the  obturator  fascia. 

Between  this  sheath  of  the  prostate  and  its  capsule  various  fibrous 
prolongations  pass,  surrounding  the  venous  plexus  in  a  mesh,  and 
binding  the  prostate  in  place.  Above  the  prostate  these  fibrous 
prolongations  form  a  more  or  less  firm  septum,  separating  the  pericap- 
sular  space  around  one  lateral  lobe  from  that  about  the  other,  and 
also  serving  as  a  medium  of  support.  In  cases  of  long-standing 
prostatitis  and  periprostatitis  the  strength  of  these  fibrous  partitions 
extending  among  the  venous  plexus  becomes  much  increased,  and 
great  force  may  be  necessary  to  tear  the  prostate  out  of  its  enveloping 
sheath. 

Thus  it  is  seen  that  the  prostate  is  enclosed  more  or  less  concen- 
trically first,  in  its  own  capsule;  then  within  its  venous  plexus  at  the 
sides  and  anteriorly,  and  by  the  bladder  above;  and,  finally,  outside  of 
the  venous  plexus  again,  passes  the  sheath  of  the  prostate. 

The  Prostatic  Plexus. — ^The  dorsal  vein  of  the  penis  passes  beneath 
the  subpubic  ligament,  being  provided  just  before  its  passage  with 
valves,  sometimes  three  in_number;  and  then  divides  into  two  branches 


Nerves  and  Vessels  3? 

which  clothe  the  sides  of  the  prostate.  Here  it  is  joined  by  veins  from 
the  substance  of  the  prostate,  and  by  other  minor  tributaries,  forming 
the  venous  plexus  of  Santorini.  No  tributaries,  however,  come  from 
the  parietal  veins  of  the  pelvis.  This  plexus  lies  chiefly  on  the  anterior 
and  lateral  aspects  of  the  prostate,  and  its  veins,  like  others  in  the 
pelvis,  and  in  spite  of  the  large  number  of  valves  present,  are  prone  to 
become  engorged.  In  the  aged  they  frequently  become  varicose,  and 
the  formation  of  phleboliths  is  not  at  all  uncommon. 

This  plexus  lies  within  the  meshes  of  the  sheath  of  the  prostate, 
entirely  outside  of  its  capsule.  Its  veins  travel  backward,  receiving 
veins  from  the  the  sides  and  base  of  the  bladder,  and  from  the  cellular 
tissue  about  the  rectum,  and  finally  empty  into  the  internal  iliac 
veins.  Fenwick  has  shown  that  this  important  plexus  has  three  dis- 
tinct sets  of  valves,  which  all  tend  to  prevent  backward  pressure. 
One  set  is  found  at  the  commencement  of  the  system;  one  at  the  end, 
in  the  internal  iliac  veins;  and  a  third  set,  which  is  less  constant,  about 
the  middle  of  the  plexus.  .  Practically  all  the  veins  which  enter  this 
plexus  are  valved,  so  that  Fenwick  compares  the  condition  to  that  of 
a  series  of  rooms  with  many  different  entrances,  but  only  one  exit,  the 
result  being  that  the  direction  of  the  current  is  normally  always 
straight  onward.  The  branches  received  from  the  internal  pudic 
veins  and  from  the  perirectal  veins  are  powerfully  valved,  so  that 
normally  no  regurgitation  into  the  hemorrhoidal  circulation  can  take 
place. 

The  Arteries. — The  arteries  of  the  prostate  are  numerous  but  insig- 
nificant. They  arise  from  the  internal  pudic,  the  inferior  vesical,  and  the 
middle  hemorrhoidal  arteries.  The  largest  is  the  prostatic  artery,  de- 
rived from  the  hypogastric  axis,  passing  along  on  the  lower  part  of  the 
sides  of  the  bladder  to  the  prostate.  The  twigs  given  off  from  this  artery 
on  the  surface  of  the  prostate  in  part  supply  its  substance,  piercing  its 
capsule,  and  in  part  anastomose  with  twigs  from  the  corresponding 
artery  on  the  opposite  side,  above  the  prostate.  There  are  seldom 
many  communicating  branches  below  the  gland,  while  the  branches 
from  the  internal  pudic  and  middle  hemorrhoidal  are  rarely  of  sufficient 
size  to  be  noticed. 

Sometimes  the  internal  pudic  artery  is  smaller  than  usual,  and  its 
terminal  branches  are  then  derived  from  the  vesico-prostatic,  or  from 
an  accessory  pudic  artery,  rising  from  the  internal  pudic  artery  just 
before  its  passage  through  the  great  sacro-sciatic  foramen.  When  they 
are  derived  from  the  accessory  pudic,  they  may  be  wounded  in  opera- 


36  Anatomy 

tions  on  the  perineum;  but  when  springing  from  the  vesico-prostatic, 
they  He  above  the  prostate  and  urethra,  and  are  not  so  liable  to  injury. 

Nerves. — In  the  section  of  this  work  devoted  to  the  physiology 
of  the  sexual  organs,  we  have  referred  to  certain  differences  of  opinion 
that  exist  among  experimentalists  regarding  the  location  of  the  spinal 
centres  controlling  erection  and  ejaculation.  And  so  it  is  with  the 
peripheral  nerve  pathways  carrying  fibres  to  and  from  the  spinal 
centre  or  centres.  The  prostate  gland  is  innervated  by  fibres  largely 
derived  from  the  sympathetic  system  through  the  pelvic  or  inferior 
hypogastric  plexus,  some  medullated  fibres  being  also  found. 

The  bladder,  the  urethm  and  the  cavernous  tissue  of  the  penis  are 
said  to  receive  their  nerve  supply  from  this  same  source,  thus  explain- 
ing the  reflex  pain  felt  at  the  end  of  the  penis  in  certain  affections  of  the 
bladder. 

To  this  statement  should  be  added  that  the  verumontanum,  the 
ejaculatory  ducts,  the  vasa  def erentia,  and  the  vesiculae  seminales  are 
similarly  innervated,  and  that  the  functions  of  erection,  ejaculation, 
and  urination  are  presided  over  by  nerve  fibres  running  in  these 
same  pathways. 

According  to  Eckhard,  contraction  of  the  prostatic  musculature  is 
dependent  upon  impulses  carried  by  both  tjie  nervi  erigentes  and  the 
hypogastrics;  the  former  being  purely  motor,  whereas  the  latter  are 
both  motor  and  secretory.  The  nervi  erigentes  were  found  by 
Eckhard  to  arise  in  the  dog  from  the  first  and  second  sacral  nerves,  and 
sometimes  also  from  the  third  sacral  nerve.  Stimulation  of  these 
nerves  caused,  among  other  phenomena,  expulsion  of  prostatic  fluid. 
Loeb  found  that  stimulation  of  the  hypogastrics  caused  contraction  of 
the  prostatic  tubules;  Nuslowsky  and  Bormann  not  only  con- 
firmed this  observation,  but  also  demonstrated  that  stimulation  of 
these  nerves  promotes  secretory  activity  in  the  glandular  cells  of  the 
prostate. 

Langley  and  Anderson,  on  the  contrary  state,  that  the  internal  genera- 
tive organs  of  the  cat  and  of  the  rabbit  are  not  influenced  by  stimulation 
of  the  sacral  nerves.  In  these  animals,  they  found  that  the  nerves 
to  the  genital  organs  are  carried  in  the  anterior  roots  of  the  third,  fourth, 
and  fifth  lumbar  nerves  and  sometimes  also  the  second.  The  fibres 
pass  through  the  sympathetics  to  the  inferior  mesenteric  ganglia 
and  continue  their  course  by  way  of  the  hypogastric  nerves.  Stimula- 
tion of  these  nerves  is  said  by  them  to  have  caused  emission  of  semen 
from  the  urethra. 


Microscopic  Anatomy  37 

As  regards  the  innervation  of  the  human  prostate,  the  weight  of 
the  evidence  seems  to  favor  the  nervi  erigentes  of  Eckhard  together 
with  the  hypogastrics. 

The  Lymphatics. — The  lymphatics  are  both  deep  and  superficial. 
The  former  occupy  the  smaller  vessels  in  the  stroma  of  the  gland, 
while  the  superficial  series  Hes  with  the  venous  plexus  between  the 
prostatic  capsule  and  its  sheath.  These  are  eventually  joined  by  the 
deep  vessels  to  form  a  network  on  the  lower  and  posterior  surface  of 
the  organ.  This  network  is  drained  by  two  trunks  on  either  side— a 
superior  and  a  lateral.  The  upper  and  smaller  trunks  are  afferent  to 
the  obturator  lymph  nodes  of  the  pelvic  wall,  while  the  lateral  and  larger 
ones  terminate  in  the  internal  iliac  nodes. 

Microscopic  Anatomy. — Histologically  the  prostate  is  classified  as  a 
compound  tubular  gland.  The  acini  are  embedded  in  a  meshwork  of 
involuntary  muscle  and  fibrous  tissue,  the  latter  extending  as  septa 
inward  from  the  prostatic  capsule,  which  latter  is  formed  by  a  peripheral 
condensation  of  the  stroma  of  the  organ.  Among  the  muscular  and 
fibrous  tissues  and  around  the  acini  are  found  the  arterial  twigs,  the 
venous  radicles,  and  the  deep  set  of  lymphatic  vessels.  The  ultimate 
distribution  of  the  nerves  is  not  definitely  known. 

The  glandular  tissue  is  most  marked  in  the  two  lateral  lobes  and  is  in 
greater  evidence  toward  the  base  than  toward  the  apex  of  the  organ. 
During  the  development  of  the  prostate  gland  three  of  its  original 
groups  of  tubules  become  overshadowed  by  the  greater  development  of 
the  remaining  two  groups,  the  latter  forming  the  lateral  lobes  which 
constitute  the  major  portion  of  the  adult  gland.  Nevertheless  it  is 
possible,  as  Lowsley  has  shown,  to  demonstrate  microscopically  the 
presence  of  gland  groups  in  the  adult  prostate  which  are  distinct  and 
separate  from  those  forming  the  lateral  lobes.  These  from  their  loca- 
tion in  respect  to  the  position  of  the  lateral  lobes  are  termed  anterior, 
middle,  and  posterior  lobes,  respectively.  These  collections  of  tubules 
are  not  grouped  together  in  such  manner  that  they  form  lobes  which 
can  be  recognized  in  the  gross  specimen,  but  they  are  of  more  than 
academic  interest  for  the  reason  that  their  participation  in  neoplastic 
diseases  of  the  prostate  changes  materially  the  clinical  picture.  To 
understand  the  mechanics  of  prostatic  obstruction  at  the  vesical  outlet 
one  must  appreciate  the  part  that  neoplasms  originating  in  each  of  the 
five  groups  of  tubules  play. 

The  number  of  tubules  in  each  of  the  five  lobes  varies  within  wide 
limits.    Lowsley  studied  many  specimens  in  serial  section  following  each 


38  Anatomy 

tubule  from  its  most  peripheral  portion  to  the  duct  orifice;  his  findings 
are  tabulated  as  foUows: 

Middle  lobe 0-12-average-io 

Right  lateral  lobe 10-23             ~i6 

Left  lateral  lobe 11-23             -16 

Posterior  lobe 6-1 2             -  9 

Anterior  lobe 2-14             -  7 

The  total  average  number  of  tubules  he  found  to  be  fifty  eight, 
which  is  a  far  greater  number  than  is  generally  ascribed  to  the  organ. 
The  number  of  tubules  is  somewhat  greater  in  young  specimens  but 
after  the  age  of  puberty  the  number  of  branches  is  markedly  increased 
and  the  complexity  of  the  gland  structure  is  far  greater  than  it  is  in 
younger  specimens.  Branching  of  the  prostatic  tubules  is  most  marked 
near  the  periphery  of  the  organ.  The  tubules,  as  Lowsley  has  demon- 
strated, "run  obliquely  through  the  muscular  and  elastic  tissues  which 
form  the  bulk  of  the  gland,  and  upon  reaching  the  peripheral  fourth 
spread  out  in  many  small  branches  nearly  all  of  which  point  posteriorly 
or  toward  the  base  of  the  prostate  and  resemble  very  closely  a  wind- 
blown umbrella  tree  with  the  forward  half  of  its  branches  removed." 

The  ducts  from  each  of  the  five  original  groups  of  tubules  empty 
into  the  portion  of  the  urethra  from  which  they  originally  developed. 
In  the  actively  functioning  prostate  the  glandular  portion  constitutes 
approximately  one-third  of  the  bulk  of  the  organ,  due  in  part  to  the 
greater  number  of  tubular  branches  present,  and  also  to  the  disten-' 
tion  of  the  tubules  with  glandular  secretion.  The  ducts  are  lined  close 
to  their  orifices  in  the  urethra  with  a  prolongation  of  the  transitional 
epithelium  with  which  the  prostatic  urethra  is  lined ;  deeper  in  they  are 
lined  with  a  single  layer  of  columnar  epithelium  without  a  distinct  base- 
ment membrane.  The  acini  themselves  are  paved  with  simple  colum- 
nar epithelium  which  though  usually  in  a  single  layer,  is  frequently 
stratified,  smaller  polyhedral  elements  filling  up  the  crevices  between 
the  columnar  cells.  The  cells  lining  the  acini  are  often  granular  in 
appearance,  and  the  nuclei  are  placed  nearer  to  the  basement  membrane 
than  to  the  free  end  of  the  cells. 

The  prostatic  tubules  comprising  the  various  groups  differ  very 
slightly  in  minute  structure.  Their  distribution  within  the  glandular 
stroma  and  the  relationship  which  they  bear  to  each  other  is  interesting. 
The  following  description  of  them  is  largely  based  on  Lowsley's  careful 
and  thorough  microscopic  studies  of  the  actively  functioning  gland. 

The  anterior  lobe  is  composed  of  from  two  to  fourteen  short  tubules 


Microscopic  Anatomy  39 

which  are  surrounded  by  a  thin  muscular  and  connective  tissue  stroma. 
The  ducts  open  on  the  ventral  wall  of  the  urethra  above  the  point  where 
the  ejaculatory  ducts  open.  Lowsley  quotes  Kuzuitzky  as  having 
found  a  persistent  ventral  lobe  in  one  out  of  every  fifteen  adult  prostates. 
Two  cases  are  mentioned  which  showed  benign  hypertrophy  of  the 
anterior  lobe. 

The  middle  lobe  is  made  up  of  ten  tubules  on  the  average.  They 
are  markedly  branched  resembling  in  this  respect  the  tubules  of  the 
lateral  lobes.  The  middle  lobe  occupies  that  portion  of  the  gland 
bounded  by  the  bladder,  the  ejaculatory  ducts,  the  urethra,  and  the  two 
lateral  lobes.  The  middle  lobe  tubules  are  quite  distinct  from  those  of 
the  lateral  and  posterior  lobes,  being  separated  from  them  by  definite 
fascial  planes.  Their  ducts  open  on  the  floor  of  the  urethra  posterior 
to  the  verumontanum.  The  tubules  project  upward  behind  the  sphinc- 
ter of  the  bladder,  some  of  them  lying  in  contact  with  its  fibres  but 
none  of  them  actually  projecting  within  the  sphincter  muscle.  This 
relationship  is  important  to  remember  in  the  study  of  intravesical 
growths  originating  from  the  middle  lobe. 

The  lateral  lobes  are  the  largest  of  the  prostatic  lobes.  Each  lateral 
lobe  consists  of  sixteen  large  and  branching  tubules  whose  ducts  open 
into  the  urethra  in  the  prostatic  furrows  on  either  side  of  the  verumon- 
tanum and  is  on  the  sides  of  the  structure.  These  tubules  extend  upward 
behind  the  sphincter  but  are  contained  within  the  fibrous  capsule  of 
the  gland,  differing  in  this  respect  from  the  middle  lobe  tubules  some  of 
which  penetrate  and  extend  beyond  this  envelope.  The  capsule  of 
the  prostate  is  very  thin  in  the  region  of  the  base  of  the  gland  especially 
at  the  point  where  the  urethra  enters  it.  This  point  of  weakness  in  the 
sheath  explains,  in  part  at  least,  the  tendency  of  neoplasms  originating 
either  from  the  middle  or  the  lateral  lobes,  to  invade  the  bladder  by 
way  of  the  urethral  orifice. 

The  majority  of  the  tubules  of  the  lateral  lobes  are  directed  upward, 
a  few  project  toward  the  triangular  ligament  and  occupy  the  apical 
portion  of  the  gland.  Practically  all  of  the  duct  orifices  are  found  on  a 
level  with,  or  distal  to  the  openings  of  the  ejaculatory  ducts  and 
are  therefore  distinctly  separated  from  the  openings  of  the  middle 
lobe  ducts  which  open  on  the  floor  of  the  urethra  proximal  to  the 
verumontanum. 

The  posterior  lobe  consists  on  the  average  of  nine  tubules.  This 
is  the  least  definite  of  the  lobes  in  the  adult  specimen.  The  tubules 
comprising    it    are   in   intimate    association    with    the   lateral  lobes; 


40  Anatomy 

its  ducts  as  well  as  those  of  the  lateral  lobes  open  in  the  prostatic  furrows 
and  on  the  sides  of  the  verumontanum  distal  to  the  openings  to  the 
ejaculatory  ducts.  Lowsley  compares  the  posterior  lobe  to  a  wedge 
"with  its  base  at  the  apex  of  the  prostate,  its  apex  being  found  posteri- 
orly from  the  point  where  the  ejaculatory  ducts  begin  their  oblique 
passage  through  the  prostate. " 

The  boundaries  of  the  posterior  lobe  are,  the  ejaculatory  ducts  and 
the  lateral  lobes  anteriorly,  the  base  of  the  prostate  above,  the  apex  of 
the  prostate  below,  and  the  lower  or  rectal  surface  of  the  prostate 
posteriorly. 

In  some  places  a  thick  sheet  of  fibro-elastic  tissue  separates  the 
lateral  and  the  posterior  lobe  tubules,  but  elsewhere  the  dividing  line  is 
most  indistinct.  According  to  the  investigations  of  W.  H.  Boyd  and  of 
J.  T.  Geraghty,  benign  hypertrophy  rarely  if  ever  originates  in  the  poste- 
rior lobe,  while  primary  cancer  rarely  or  never  begins  in  any  other 
portion. 

After  careful  dissection  of  forty-two  specimens,  including  a  number 
of  bodies  of  patients  upon  whom  prostatectomy  had  been  performed — 
in  one  instance  two  years  before — Tandler  and  Zuckerkandl  conclude 
that  generalized  hypertrophy  of  the  prostate  does  not  occur  and 
that  hypertrophy  of  the  posterior  lobe  is  practically  unknown.  The 
middle  lobe,  on  the  contrary,  was  so  often  found  the  seat  of  adenoma- 
tous growths  that  these  investigators  conclude  that  the  middle  lobe 
tubules  are  chiefly  concerned  in  prostatic  hypertrophy,  and  that  much 
of  the  remaining  portion  of  the  gland  suffers  pressure  atrophy  as  the 
result  of  the  encroachment  of  the  enlarging  tumor  mass. 

A  further  proof  that  the  posterior  lobe  tubules  are  not  involved  in 
benign  hypertrophic  processes  is  found  in  the  fact  that  in  practically  all 
cases  the  ejaculatory  ducts  are  displaced  posteriorly.  This  would  not 
occur  if  the  tumor  mass  took  origin  in  the  posterior  lobe  tubules  which 
lie  posterior  to  the  ejaculatory  ducts. 

Lowsley  calls  attention  to  the  fact  that  in  the  performance  of  a 
perineal  prostatectomy  the  thick  surgical  capsule  which  must  be  cut 
through  before  exposure  of  the  adenomatous  masses  can  be  made, 
is  composed  of  the  compressed  tubules  and  the  stroma  of  the  posterior 
lobe.  Histologically  the  posterior  lobe  tubules  differ  only  slightly  from 
those  of  the  lateral  lobes. 

Accessory  Glands. — Certain  glandular  structures  of  independent 
origin,  and  probably  having  no  functional  relationship  with  the  prostate 
gland,  are  found  in  the  region  of  the  internal  vesical  sphincter.     The 


Microscopic  Anatomy  41 

most  important  of  these  are  the  subcervical  group  of  Albarran,  which 
consists  of  thirty  or  more  branched  tubules  whose  ducts  open  in  the 
mid-line  of  the  floor  of  the  urethra  proximal  to  the  verumontanum. 
The  tubules  grow  entirely  within  the  sphincter  muscle  of  the  bladder 
and  occupy  for  the  most  part  the  mucosa,  some  few  penetrating  into 
the  submucous  coat. 

They  differ  from  the  prostatic  tubules  in  that  they  are  simpler  in 
structure  and  are  lacking  in  a  definite  muscular  and  connective  tissue 
stroma.  Their  importance  lies  in  the  fact  that  they  are  subject  to 
frequent  pathological  changes  resulting  in  enlargement,  and  consequent 
obstruction  to  the  vesical  outlet.  In  twenty-four  per  cent,  of  post- 
mortem specimens  taken  from  men  over  thirty  years  of  age,  Lowsley 
found  these  glands  enlarged  sufficiently  to  cause  demonstrable  signs  of 
obstruction  in  the  bladder.  The  same  writer  describes  a  second  group 
of  glands,  which  he  calls  the  sub  trigonal  group  of  tubules,  as  follows: 

"They  occur  in  the  mucosa  of  the  trigonum  vesicae  usually  below 
the  central  point  and  are  found  as  far  anteriorward  as  its  apex.  They 
are  for  the  most  part  simple  tubules  which  extend  to  the  submucosa 
and  somewhat  into  it.  In  the  younger  specimens  there  are  no 
branches,  but  some  of  those  found  during  the  middle  age  period  show 
one  or  two  small  branches.  There  is  nothing  distinctive  about  the 
structure  of  the  members  of  the  subtrigonal  group.  The  mucous 
lining  is  composed  of  transitional  epithelium  similar  in  type  to  the 
vesical  mucosa.  The  cells  are  much  piled  up,  in  some  cases  five  or 
six  deep.  Their  lumina  are  quite  small,  as  a  rule.  These  tubules  are 
of  importance  on  account  of  two  facts:  because  their  position  is  such 
that  an  overgrowth  or  enlargement  from  any  cause  will  bring  about 
a  disturbance  in  the  emptying  of  the  bladder;  secondly,  because  an 
enlargement  of  the  group  does  occur  in  a  small  percentage  of  cases.  I 
have  observed  six  non-malignant  tumors  of  the  trigonum  vesicae  intra- 
vitam  and  three  in  post-mortem  specimens.  The  number  of  these 
finger  formed  tubules  increases  markedly  after  birth  but  are  found  in 
the  embryo  after  the  fourth  month.  More  than  twenty  of  them  are 
observed  in  every  specimen  older  than  four  years." 

Young  has  described  cases  with  pedunculated  tumors  originating 
from  the  subtrigonal  group  of  tubules  which  caused  obstruction  by 
blocking  the  vesical  outlet. 

Verixmontanum,  Caput  Gallinaginis  and  Uterus  Masculinus  are 
terms  applied  to  an  elevation  situated  on  the  floor  of  the  prostatic 
urethra  at  about  its  mid-point.     The  verumontanum  averages  2.0  cm. 


42  Anatomy 

in  length,  0.41  cm.  in  width  and  0.3  cm.  in  height.  It  is  covered  with 
a  mucosa  identical  in  structure  with  the  general  lining  of  the  prostatic 
urethra.  The  mucous  membrane  is  thrown  into  longitudinal  folds 
above  and  below  the  verumontanum;  the  upper  folds,  varying  in 
number  from  one  to  five,  are  in  continuity  with  the  uvulae  vesicae, 
the  lower  folds  continue  downward  to  the  membraneous  urethra. 

The  verumontanum  is  merely  a  mound  caused  by  the  elevation 
of  the  floor  of  the  urethra  as  the  result  of  the  passage  beneath  it  at 
this  point  of  the  ejaculatory  ducts  and  the  presence  between  them  of 
the  utriculus  prostaticus  or  sinus  pocularis,  whose  walls  contribute 
to  the  formation  of  the  verumontanum.  The  sinus  pocularis  represents 
the  remains  of  the  fused  Miillerian  ducts  and  is  therefore  the  homo- 
logue  of  the  female  uterus.  The  sinus  pocularis  is  a  narrow  canal 
lined  with  mucous  membrane  whose  mouth,  which  averages  0.17  cm. 
in  width,  opens  on  the  summit  of  the  verumontanum.  It  extends 
upward  and  backward  for  a  distance  varying  from  o.i  cm.  to  0.7  cm. 
The  lining  membrane  is  clothed  with  stratified,  ciliated  columnar 
epithelium.  Eight  or  more  compound  tubular  glands  are  in  communi- 
cation with  the  cul-de-sac.  ,The  tissues  surrounding  the  sinus  pocu- 
laris were  at  one  time  believed  to  be  erectile,  and  turgescence  of  these 
tissues  was  supposed  to  cause  the  verumontanum  to  increase  in  size  and 
to  prevent  the  reflux  of  semen  into  the  bladder  during  ejaculation. 
The  presence  of  erectile  tissue  in  this  region  is  now  disproved. 

The  ejaculatory  ducts  begin  well  within  the  glandular  portion  of 
the  prostate,  being  formed  by  the  junction  of  the  vasa  deferentia  and 
the  ducts  of  the  seminal  vesicles.  They  lie  quite  close  together  and  the 
peripheral  portion  of  the  muscle  fibres  surrounding  them  intermingle. 
The  ducts  pass  forward  on  a  gradual  slant  until  they  reach  the  posterior 
border  of  the  verumontanum  in  the  substance  of  which  they  run  parallel 
with  the  axis  of  the  urethra.  At  the  mid-point  of  the  verumontanum 
they  turn  sharply  lateralward  and  open  on  the  sides  of  this  structure. 
These  ducts  which  are  approximately  two  centimetres  in  length  are 
surrounded  near  their  orifices  by  sphincter  muscles  which  are  merely 
a  thickening  of  the  common  circular  coat.  Their  openings  are  further 
protected  by  valve-like  folds  of  mucous  membrane  which  serve  to  close 
their  lumina  when  the  intra-urethral  pressure  is  elevated.  The  ejacu- 
latory ducts  near  their  terminals  are  lined  with  transitional  epithelium 
which  is  replaced  by  cuboidal  epithelium  at  deeper  levels. 

The  musculature  of  the  prostate  is  in  intimate  anatomic,  and, 
possibly,  physiologic  relationship  with  the  musculature  of  the  pros- 


Microscopic  Anatomy 


43 


Fig.  II. — Urethra  and  Bladder  Laid  Open  from  Above,  showing  in  the  Bulbous 
Urethra,  the  Orifices  of  the  Ducts  of  Cowper's  Glands,  and  in  the  Pbosiatic 
Urethra  the  Orifice  of  the  Uterus  Masculinus,  with  the  Openings  of  the  Prosta- 
tic Ducts  on  Each  Side  of  the  Verumontanum.  Note  the  Orifices  of  the  Ejao 
ulatory  Ducts  on  the  Margins  of  the  Orifice  of  the  Uterus  Masculinus. 


44 


Anatomy 


tatic  urethra  and  bladder.  These  relationships  are  discussed  at  some 
length  in  the  chapter  devoted  to  the  physiology  of  the  prostate  gland. 
SuflSce  it  to  say  here  that  the  muscular  fibres  of  the  prostate  are  arranged 
in  a  compact  layer  around  its  periphery,  forming  with  the  contiguous 
fibrous  tissue,  the  true  capsule  of  the  gland.  Wallace  asserts  that 
striped  as  well  as  unstriped  muscular  fibres  are  found  among  the  gland- 
ular elements  of  the  normal  prostate.  Prolongations  from  the  capsule 
penetrate  between  the  glandular  elements,  thus  providing  the  gland  with 


JiiSo-jtfrosfatic  //'gfa/nenJ 


jPez-itoneum 


oneurosis  <>/I?enonvil//.ers 


/v'ostate 
layer »/ Triangular  ligament 
lai/er  'J  Tria/rg'i/Jar  /x^ament 

Fig.  12. — Sheath  of  Prostate  in  Sagittal  Section  (Diagrammatic). 

a  fibromuscular  stroma.  Each  branch  of  every  tubule  is  surrounded 
by  a  heavy  muscular  envelope.  According  to  Walker,  the  circular 
muscle  fibres  surrounding  the  acini  are  more  developed,  while  the  ducts 
are  provided  with  more  robust  fibres  longitudinally   disposed. 

The  terminals  of  the  prostatic  ducts  are  provided  with  sphincter 
muscles:  these  are  merely  localized  thickening  of  the  circular  fibres 
which  elsewhere  are  poorly  developed. 

Walker  has  described  collections  of  small  round  cells  in  the  prostate 
gland.  These  he  regards  as  lymph-nodes,  but  the  presence  of  lymph 
channels  has  not  been  demonstrated  except  at  the  periphery  of  the 
gland.     Weski  has  studied  these  structures  in  human  prostates  and 


Microscopic  Anatomy 


45 


believes   them   to  be   normal  anatomic   structures;  Waldeyer  found 
similar  structures  in  the  prostate  gland  of  the  dog. 

Collections  of  round  cells  are  not  found  in  the  prostate  before  the 


lecto-vesicai  fascia  '^"^r^^-v^ 
,/st.  J)i vision  ^^   j  \ 
,2nd.  Dl vision  -^   j 
,  3rd.  Hi  vision  ^ 


Obturator 
In.ter/?.i/,s 

AnalJascicL-^ 
Zaoatorjinl 


Fig.  13. — Sheath  of  Prostate  in  Transverse  Section.    Line  of  Section  shown  in 
THE  Lower  Drawing.     (Diagrammatic.) 

age  of  puberty,  so  that  many  observers  regard  them  merely  as  evidence 
of  inflammation. 

Elastic  tissue  is  demonstrable  in  the  prostate  gland.  It  encircles 
the  urethra  and  sends  processes  in  the  form  of  a  figure  eight  to  sur- 
round the  prostatic  ducts,  just  beneath  the  mucous  membrane. 


46 


Anatomy 


The  Lymphatics. — The  lymphatics  are  both  deep  and  superficial. 
The  former  accompany  the  smaller  vessels  in  the  stroma  of  the  gland, 
while  the  superficial  series  lies  with  the  venous  plexus  between  the  pros- 
tatic capsule  and  its  sheath.  These  are  eventually  joined  by  the 
deep  vessels,  and  together  they  empty  into  the  lymphatics  along  the 
course  of  the  internal  iliac  vessels. 


Fig.  14. — Normal  Urethra,  showing  Dilatability. 
A.  Fossa    navicularis.    D.  Bulbous    urethra.     B.  Membranous    urethra.     C.  Prostatic 

urethra. 

The  Prostatic  Urethra  extends  from  the  bladder  above  to  the 
deep  layer  of  the  triangular  ligament  below,  where  it  becomes  the 
membranous  urethra.  Its  course  is  at  first  downward,  but  toward 
the  termination  of  the  membranous  portion  it  has  commenced  its 
upward  journey,  which  is  continued  in  the  bulbous  portion  until  the 
penile  urethra  is  reached,  when  the  curve  again  changes,  and  here  has 
its  convexity  upward.     The  prostatic  urethra  is  from  two  to  two-and 


Microscopic  Anatomy 


47 


Fig.  15. — Coronal  Section  of  the  Pelvis,  through  the  Prostate  and  the 
Membranous  Urethra,  showing  the  Triangular  Ligament  of  the  Perineum.  View 
of  the  Anterior  Surface  of  the  Posterior  Segment  of  the  Pelvis. — (Spalteholz.) 


Fig.  16.^- View  of  the  Pelvis  from  Behind. 
Note  the  white  line  of  origin  of  the  levator  ani;  the  relations  of  the  ureters,  vasa 
deferentia,  and  seminal  vesicles.     The  prostatic  sheath  is  weU  shown,  also  the  two  layers 
of  the  recto-prostatic  fascia  (aponeurosis  of  DenonviUiers),  and  between  them  the  deep 
layer  of  the  triangular  ligament. 


48  Anatomy 

a-half  centimetres  in  length,  and  normally  has  its  sides  in  contact.  Its 
floor  is  raised  by  the  verumontanum  or  caput  gallinaginis  so  that  on 
cross-section  it  presents  a  crescentic  outline,  with  convexity  above. 
Its  internal  diameter  is  about  eight  millimetres,  but  it  is  the  most  dilat- 
able part  of  the  whole  canal.  On  its  superior  wall,  just  beneath  the 
mucous  membrane,  are  numerous  good-sized  veins,  which,  when 
engorged,  may  easily  be  ruptured  by  a  catheter  carelessly  passed.  The 
mucous  membrane  of  the  prostatic  urethra  is  convoluted  into  longi- 
tudinal folds  when  no  urine  is  passing,  and  hence  is  readily  adapted  to 
changes  in  calibre  of  this  canal. 

Relational  or  Applied  Anatomy. — Although  the  state  of  the  parts 
surrounding  the  prostate  is  of  greater  anatomic  interest  to  the  sur- 
geon when  altered  by  disease,  yet  a  clear  understanding  of  such 
pathologic  changes  can  only  be  acquired  by  a  thorough  knowledge 
of  the  normal  relations. 

Placed  in  the  true  pelvic  cavity,  below  the  bladder,  above  the 
rectum,  and  about  one-and-a-half  centimetres  behind  the  lower  margin 
of  the  pubic  symphysis,  the  prostate  is  held  quite  firmly  in  place  by 
the  supporting  fasciae. 

From  the  bladder  it  is  separated  only  by  a  thin  layer  of  fascia 
(the  first  of  the  three  subdivisions  of  the  recto-vesical  fascia)  which 
becomes  blended  with  the  outer  coat  of  the  bladder  and,  in  the  middle 
line,  with  the  capsule  of  the  prostate.  Hence  on  incising  the  mucous 
membrane  of  the  bladder,  as  soon  as  the  muscularis  mucosae  is  divided, 
this  layer  of  fascia  presents  itself,  forming  the  sheath  of  the  prostate; 
and  as  there  are  in  this  situation  no  veins  of  any  size  between  the 
prostatic  sheath  and  its  capsule,  the  sheath  and  capsule  are  here 
practically  in  contact.  When  the  prostate  becomes  much  enlarged, 
this  layer  of  fascia  atrophies  or  is  pushed  to  one  side,  and  the  pro- 
static capsule  presents  itself  immediately  beneath  the  vesical  mucous 
membrane. 

To  the  rectum  the  prostate  is  rather  firmly  attached  by  fibrous 
connective  tissue,  which  may,  with  care,  be  separated  into  two  layers, 
prolongations  of  the  recto-vesical  fascia;  the  lower  layer  blends  with 
the  fibrous  covering  of  the  rectum,  while  the  upper  sends  processes 
around  the  seminal  vesicles  and  ampullae  of  the  vasa  deferentia,  besides 
passing  below  the  prostatic  plexus  of  veins  to  join  a  similar  layer  from 
the  other  side.  This  layer  remains  after  the  removal  of  the  gland  by 
suprapubic  prostatectomy,  and,  with  that  immediately  subjacent, 
effectually  prevents  urinary  extravasation  into  the  perirectal  and 


Applied    Anatomy  4q 

subperitoneal  cellular  tissues.  These  two  layers  of  fascia  together 
form  the  aponeurosis  of  Denonvilliers,  and  the  rectum  cannot  be 
safely  stripped  back  from  the  prostate  in  the  operation  of  perineal 
prostatectomy  until  the  inferior  layer,  which  is  the  stronger,  has  been 
divided;  by  so  doing  the  surgeon  is  admitted  into  the  "espace  de- 
collable  retroprostatique,"  so  eloquently  described  by  Proust. 

The  recto-vesical  fascia  forms  two  thicker  bands  of  fascia  in  the 
median  line  anteriorly,  known  as  the  pubo-prostatic  ligaments  or 
anterior  true  ligaments  of  the  bladder.  These  are  attached  above  to 
the  pubic  bones  on  each  side  of  the  symphysis,  and  are  inserted  below 
into  the  capsule  of  the  prostate  on  its  upper  surface,  and  into  the 
anterior  surface  of  the  bladder.  When  we  say  inserted  into  the  capsule 
of  the  prostate,  we  wish  it  to  be  understood  that  here,  as  elsewhere,  the 
prostatic  plexus  of  veins  lies  immediately  outside  the  capsule  of  the 
prostate  gland,  and  that  the  insertion  above  described  takes  place  by 
processes  of  fascia  sent  between  the  veins  where  they  are  numerous, 
and  by  a  coalescence  of  the  sheath  with  the  capsule  where  the  veins 
are  absent.  The  dorsal  vein  of  the  penis,  after  perforating  the  deep 
layer  of  the  triangular  ligament  of  the  perineum,  lies  in  the  interval  be- 
tween the  two  pubo-prostatic  ligaments,  and  as  they  pass  on  to  their 
insertion  into  the  bladder,  it  subdivides  beneath  them  into  the  pros- 
tatic plexus.  Because  fibres  of  involuntary  muscle,  prolonged  from 
the  bladder-wall,  are  found  beneath  the  pubo-prostatic  ligaments, 
they  are  also  called  the  pubo-prostatic  muscles. 

In  the  median  line  anteriorly  the  recto-vesical  fascia  (pubo-pros- 
tatic ligaments)  is  in  contact  beneath  the  pubic  arch  with  the  deep 
layer  of  the  triangular  ligament  of  the  perineum  (the  dorsal  vein  of  the 
penis  intervening) ;  but  to  each  side  of  the  median  line  these  structures 
are  separated  by  the  most  anterior  fibres  of  the  levatores  ani  muscles, 
which  in  this  situation  were  denominated  by  Santorini  the  levatores 
prostatae.  These  muscular  fibres  descend  upon  the  sides  of  the  pros- 
tate, and  unite  beneath  it;  in  this  situation  they  blend  with  the  fibres 
of  the  superficial  transverse  perineal,  and  external  sphincter  ani 
muscles,  forming  the  central  tendinous  point  of  the  perineum.  The 
deep  layer  of  the  triangular  ligament,  it  should  be  remembered,  is 
really  one  of  the  ultimate  subdivisions  of  the  pelvic  fascia,  being 
the  continuation  toward  the  median  line  of  the  obturator  fascia, 
which  lies  between  the  levator  ani  and  the  obturator  internus  muscles. 

The  urethra  emerges  from  the  prostate  gland  at  its  apex,  about 
one-and-a-half  centimetres  below  the  pubic  arch,  and  passes  through 


so 


Anatomy 


the  posterior  or  deep  layer  of  the  triangular  ligament  to  become  the 
membranous  urethra.     This  layer  of  fascia  is  firm  and  tense,   and 


accordingly  the  apex  of  the  prostate  gland  is  its  most  fixed  portion; 
enlargement  of  the  organ  necessarily  extends  backward,  upward,  or 
downward,  never  forward.     There  is  no  sharp  ring  where  the  urethra 


Prostatic    Urethra 


51 


penetrates  the  triangular  Hgament,  as  this  membrane,  instead  of  ter- 
minating abruptly  at  the  circumference  of  the  urethra,  is  reflected 
along  its  surface  toward  the  prostate,  and  blends  with  its  fibrous  coat. 
Thus  a  catheter  is  not  liable  to  be  arrested  by  any  ring-Hke  constriction 
outside  the  lumen  of  the  urethra. 


Fig.  18. — Side  View  of  the  Pelvis  showing  the  Muscles  around  the  Bladder  and 

Prostate. 
A.  Triangular  ligament.  B.  Levator  ani  muscle  of  right  side.  C.  Deep  transversus 
perinei  muscle  of  left  side  D.  Cut  edge  of  levator  ani  muscle  of  left  side.  E.  External 
sphincter  ani  muscle.  F.  Bulbo-cavernosus  muscle.  G.  Left  ureter.  H.  Vas  deferens 
(left).  K.  Coccygeus  muscle  (right).  L.  Pyriformis  muscle  (right).  The  bladder  and 
prostate  have  been  displaced  upward  so  as  to  expose  the  levator  ani. 

The  prostatic  urethra  is  normally  about  eighteen  centimetres  distant 
from  the  external  urinary  meatus.  Any  obstruction  seated  nearer  than 
this  to  the  meatus  is  not  likely  to  be  caused  by  disease  of  the  prostate. 

About  three  centimetres  within  the  anus  the  prostate  may  be  felt 


52 


Anatomy 


as  a  rounded,  firm  body  of  about  the  size  of  a  horse-chestnut  or  a 
little  larger.  By  combined  examination  with  a  sound  in  the  urethra 
and  a  finger  in  the  rectum  much  information  as  to  its  size  and  shape  may 
be  obtained. 


Fig.  19. — Side  View  of  the  Pelvis,  showing  the  Relations  of  the  Peritoneum  to 
THE  Empty  and  the  Distended  Bladder. — {After  Gerrish.) 

It  is  well  known  that  the  anterior  wall  of  the  rectum  undergoes  a 
sharp  flexure  just  within  the  anus,  so  that  the  axis  of  the  rectum  is 
practically  at  right  angles  with  that  of  the  anal  canal.  This  angle  of 
the  anterior  rectal  wall  is  produced  by  its  attachment  to  the  triangular 
ligament  of  the  perineum  by  certain  muscular  fibres  described  as  the 
recto-urethral  muscle.     The  external  sphincter  of  the  anus,  it  will  be 


Anal   Sphincter 


53 


recalled,  is  attached  anteriorly  to  the  perineal  centre,  meeting  there  with 
the  superficial  transverse  perineal  muscles  from  the  sides,  with  the 
anterior  fibres  of  the  levatores  ani  muscles  from  a  deeper  plane  poste- 


FiG.  20. — Dissection  of  the  Perineum. 
The  attachment  of  the  external  sphincter  ani  to  the  perineal  centre  has  been  divided, 
and  the  fascia  of  CoUes  has  been  reflected,  exposing  the  superficial  vessels  and  nerves 
of  the  perineum,  the  superficial  transverse  perineal  muscles,  the  ischio-cavernosus  and 
the  bulbo-cavernosus  muscles.  Posteriorly,  on  each  side  of  the  anus  are  seen  the  leva- 
tores  ani  muscles,  clothing  the  sides  of  the  rectum;  on  the  subject's  left  the  internal  pudic 
artery  and  branches  of  the  pudic  nerve  are  seen. 

riorly,  and  with  the  bulb  of  the  urethra  anteriorly.     On  a  plane  just 
beneath  these  structures  are  met  the  recto-urethral  muscle  posteriorly, 


54 


Anatomy 


and  the  triangular  ligament  containing  the  deep  transverse  perineal 
muscles  anteriorly.  To  understand  how  the  levator  ani,  which  between 
the  space  of  Retzius  and  the  pubic  symphysis  is  on  a  deeper  plane 


Fig.  21. — Dissection  of  the  Perineum. 
The  superficial  transverse  perineal  muscles,  the  bulbo-cavernosus  muscle,  and  the 
right  ischio-cavernosus  muscle  have  been  removed,  together  with  part  of  the  right  cor- 
pus cavernosum  and  a  section  of  the  corpus  spongiosum  and  urethra.  The  superficial 
layer  of  the  triangular  ligament,  the  dorsal  vein,  artery,  and  nerves  of  the  penis,  and  the 
arteries  of  the  corpus  cavernosum  are  thus  exposed. 

than  the  triangular  ligament,  can  become  superficial  to  this  structure 
and  the  recto-urethral  muscle,  it  must  be  remembered  that  the  levator 
ani  is  like  a  sling,  and  hangs  down  from  the  pubic  bones  to  surround  the 


Perineum 


55 


lower  part  of  the  rectum,  being  deficient  in  the  median  line  under 
the  pubic  arch,  and  only  becoming  superficial  to  the  triangular  ligament 
back  of  the  posterior  border  of  this  structure,  where  its  fibres  from  the 


Fig.  2  2. — Dissection  of  the  Perineum. 

The  superficial  layer  of  the  triangular  ligament  has  been  incised,  exposing  the  deep 

transversus  perinei  muscle  on  the  left  side,  and  the  internal  pudic  vessels  and  nerve  on 

the  right  side  of  the  cadaver     The  duct  of  Cowper's  gland  of  the  right  side  is  seen  as 

it  enters  the  bulbous  urethra,  after  piercing  the  superficial  layer  of  the  triangular  ligament. 

two  sides  of  the  prostate  unite  at  the  perineal  centre.     The  accompany- 
ing illustration  shows  these  relations  very  well. 

When  the  bladder  is  empty,  the  recto-vesical  fold  of  peritoneum 
reaches  as  far  as  the  base  of  the  prostate,  or  nearly  so;  but  when  the 
bladder  is  distended  with  a  moderate  amount  of  fluid,  the  peritoneal 


S6 


Anatomy 


reflection  is  probably  always  at  least  three  centimetres  above  the  base 
of  the  prostate  gland.  This  explains  why  the  bladder  was  formerly 
tapped  through  the  rectum  with  such  success,  and  shows  that  in  any 
ordinary  operation  on  the  prostate  through  the  perineum  no  fear  need 
be  entertained  of  opening  the  peritoneal  cavity. 


Fig.  23. — Dissection  oi-  the  Perineum. 
The  bulb  of  the  urethra  and  the  left  deep  transversus  perinei  muscle  have  been  re- 
moved.    On  the  subject's  left  the  deep  layer  of  the  triangular  ligament  is  exposed.     On 
the  right  Cowper's  gland  is  seen. 

The  anterior  vesical  fold  of  peritoneum  is  carried  up  about  five 
centimetres  above  the  upper  margin  of  the  symphysis  pubis  by  moder- 
ate distention  of  the  bladder;  but  as  in  suprapubic  operations  the 
peritoneum  is  usually  recognized  with  ease,  and  may  readily  be  stripped 


Perineum  cy 

off  from  the  bladder  if  more  room  is  desired,  the  relations  here  are  not 
of  such  practical  interest. 

The  ampullae  of  the  vasa  deferentia  lie  between  the  two  seminal 


Fig.  24. — Dissection  of  the  Perineum. 
The  deep  layer  of  the  triangular  ligament,  with  all  structures  superficial  to  it,  has 
been  removed,  exposing  the  perineal  portion  of  the  levator  ani  muscle  and  its  anterior 
fibres  known  as  the  levator  prostatas.  The  urethra  has  been  cut  off  at  the  apex  of  the 
prostate  gland.  The  fibres  of  the  levator  ani  passing  underneath  the  rectum  are  shown 
as  in  the  preceding  plates. 

vesicles  upon  the  rectum,  and  beneath  the  neck  of  the  bladder,  just 
above  and  lateral  to  the  prostate  gland,  where  they  can  be  felt  with  the 
finger  in  the  rectum.  The  ureters  run  lateral  and  parallel  to  the  vasa 
deferentia  where  the  latter  are  in  contact  with  the  bladder  wall;  at  a 


58 


Anatomy 


higher  level  the  ureters  lie  medial  to  the  vasa  deferentia,  the  latter 
having  crossed  beneath  the  ureters,  and  ascend  lateral  to  them.  In 
the  small  area  between  the  prostate  anteriorly,  the  vasa  deferentia  at 


Fig.  25. — Dissection  of  the  Perineum. 
The  recto- vesical  fascia,  forming  the  sheath  of  the  prostate,  and  the  levator  ani  muscle, 
have  been  incised  from  the  symphysis  to  the  anus,  and  the  rectum  has  been 
turned  backward  The  prostate,  the  seminal  vesicles,  and  the  vasa  deferentia  are  ex- 
posed. Note  the  vesico-prostate  plexus  of  veins  in  the  meshes  of  the  recto-vesical  fascia. 
The  wall  of  the  bladder  is  seen  above  the  prostate. 

the  sides,  and  the  peritoneal  reflection  above  or  posteriorly,  the  bladder 
is  in  fairly  close  relation  with  the  rectum.  This  is  the  spot  where,  when 
fluctuation  could  be  detected,  the  bladder  was  formerly  punctured  for 
retention  of  urine. 


Perineum  ^g 

The  combined  ejaculatory  duct  of  the  vas  deferens  and  the  seminal 
vesicle  of  each  side  penetrates  the  prostate  gland  through  a  transverse 
fissure  on  its  inferior  surface;  the  two  ducts  then  run  forward,  and 
empty  into  the  prostatic  urethra  on  either  side  of  the  verumontanum. 
According  to  Mr.  Freyer,  when  the  prostate  undergoes  marked  adeno- 
matous change,  its  two  lateral  lobes  tend  to  become  separated  again, 
as  they  were  during  fetal  life.  What  is  of  greater  practical  importance 
is  the  fact  that  the  ejaculatory  ducts  are  displaced  backward  in  the 
hypertrophied  state  of  the  prostate.  The  intraprostatic  portions  of 
these  ducts  are  contained  in  a  fibromuscular  septum  separating  the 
middle  and  lateral  lobes  in  front  from  the  posterior  lobe  behind.  En- 
largement of  either  the  middle  or  the  lateral  lobe  would  therefore  neces- 
sarily displace  the  ducts  backward  toward  the  inferior  or  rectal  surface 
of  the  gland. 

In  the  suprapubic  operation  of  prostatectomy  for  benign  enlarge- 
ment of  the  gland  not  only  are  the  ejaculatory  ducts  outside  the  line 
of  cleavage,  but  their  terminals  are  not  disturbed  if  care  is  taken  to 
cut  across  the  urethra  proximal  to  the  verumontanum.  In  conserva- 
tive perineal  prostatectomy  Young  takes  advantage  of  the  posterior 
displacement  of  the  ducts  in  that  the  bridge  of  tissue  containing  them 
is  not  disturbed  by  the  incisions  made  to  expose  the  enlarged  lateral 
lobes. 

REFERENCES  (CHAPTER  II) 

Albarran:  Maladies  de  la  Prostate,  1902,  p  526 

Boyd,  W.  H.:  Jour.  Am.  Med.  Ass.,  191 2,  Iviii,  620. 

Ciechanowski:  Annales  des  Maladies  des  Organes  Gen.-Urin.,  1901,  xix,  536. 

Denonvilliers:  Propositions  d'anatortiie,  de  physiologic  et  de  pathologic,  Paris  Thesis,  1857. 

Derry,  D.  E.:  "On  the  Real  Nature  of  the  So-called  Pelvic  Fascia."    Jour,  of  Anat.  and 

Physiol.,  1908,  xlii,  107. 
Eckhard:  Beitrage  zur  Anat.  und  Physiol.,  1863.  iii. 
Evatt:  Jour.  Anat.  and  Physiol.,  1909,  xliii,  314. 
Fen  wick:  Jour.  Anat.  and  Physiol.,  1885,  xix,  320. 

Freyer:  Stricture  of  the  Urethra  and  Hypertrophy  of  the  Prostate,  2d  ed.,  London,  1902. 
Griffith:  Jour.  Anat.  and  Physiol.,  1889,  xxiii,  374.  Ibid.,  1889,  xxiv,  27  236,  Lancet,  1895,  L 
Hada,  B.:  Studien  zur  Entwickelung  und  zur  normalen  pathologischen  Anatomic  der 

Prostata  mit  besondere  Berucksichtigung  der  sogenannten  Prostatahypertrophie.  Fol. 

Urol.,  1914-15,  ix,  65. 
Home,  Sir  Evcrard:  Trans.  Philos.  Soc.  London,  1805,  Paper  viii,  quoted  in  his  "Works," 

London,  181 1,  i.     "Practical  Observations  on  the  Treatment  of  the  Diseases  of  the 

Prostate  Gland." 
Hunter,  John:  Works  on  the  Venereal  Disease,  ed.  by  Palmer,  London,  1835,  279 
Jores:  Virchow's  Archiv.  f.  path.  Anat.,  1894,  cxxxv,  224. 
Kolischer:  Die  Urogeritalmuskulatur  des  Dammes,  1900. 
Langlcy  and  Anderson:  Jour,  of  Physiol.,  1891,  xii;  Ibid,  1895,  xix,  71. 


6o  Anatomy 

Loeb:  Inaug.  Dissert.,  Giessen,  1866. 

Lowsley:  Jour.  Amer.  Med.  Assn.,  1913,  Ix,  no;  Medical  Record,  1915,  Ixxxviii,  383; 

Amer.  Jour.  Anat.,  191 2,  xiii,  299;  Surg.,  Gynec.  and  Obstr.,  1915,  xx,  183. 
Louraeau:  Annales  des  Maladies  des  Organes  Gen.-Urin.,  1904,  xxii,  126. 
Morgagni:  Adversaria  Anatomia,  Lib.  4,  Animadversio,  14.  De  Sedis  et  Causis  Morborum, 

Lib.  3,  Epist.  41,  A.  19. 
Moullin,  C.  W.  Mansell:  Enlargement  of  the  Prostate,  London,  1899,  2d  ed.;  1904,  3d  ed. 

Medical  Record,  191 6,  xc,  3. 
Nassetti,  f.:  Clin.  Chir.,  191 2,  xxx,  1194. 
Nuslowsky  and  Bormann:  Centralbl.  fur  Physiol.,  1898,  xii. 
Owen:  Lectures  on  the  Comparative  Anatomy  of  the  Invertebrate  Animals,  London,  1843; 

The  Anatomy  of  the  Vertebrates,  London,  1868,  iii,  641. 
Pallin:  Beitrag  zur  Anatomie  und  Embryologie  der  Prostata  und  der  Samenblasen,  Arch. 

f.  Anat.  u.  Physiol.,  1901,  i,  135. 
Piersol,  George  A.:  Human  Anatomy,  vol.  ii,  p.  1979. 
Porosz:  Daten  zur  Anatomie  der  Prostata,  Arch.  f.  Anat.  u.  Physiol.,  1913,  Sup.  clxxii; 

Fol.  Urol.,  1914,  viii,  569. 
Proust:  Manuel  de  la  Prostatectomie  Perineale  pour  Hypertrophic,  Paris,  1903. 
Richardson,  W.  G.:  Development  and  .'Anatomy  of  the  Prostate  Gland,  London,  1904. 
Riidenger:  Zur  Anat.  der  Prostata,  des  Uterus  masculinus  und  der  Duchte  ejaculatorii; 

Festschrift  d.  Arztl.  Vereines  Miinchen,  1883,  47-67. 
Rytina,  A.:  The  Jour,  of  Urol.,  1917  i,  231. 
Santorini,  Jo.  Dominicus:  Observationes  Anatomicae,  Venetiis,  1724;  Cap.  lo,  Sect.  5,  f. 

181;  Jo.  Dominicus:  Ibid.,  loc.  cit.,  Sect.  19,  f.  199,  seq. 
Smith,  G.  E.:  "Study  of  the  Anat.  of  the  Pelvis  with  special  Reference  to  the  Fascia  and 

Visceral  Supports."     Jour,  of  Anat.  and  Physiol.,  1908,  xlii,  198. 
Strieker:  Human  and   Comparative   Histology.     Translation   of   New   Sydenham   Soc, 

London,  1872,   ii,  p.  300. 
Tandler  and  Zuckerkandl:  I-'oHa  Urologica,   191 1,  v,   587;  ibid.,   1912,  vi,  635. 
Thompson,  Sir  Idenry:  Diseases  of  the  Prostate,  London,  1868. 
Versari:  Ric.  d.  lab.  d.  Roma,  1907,  xiii. 
Wade,  Henry:  Annals  of  Surgery,  1914,  lix,  1. 
Waldeyer:  Quoted  by  Piersol. 

Walker,  George-  Johns  Hopkins  Hospital  Bulletin,  1900,  xi,  242. 
Walker,  Thomson:  Jour.  Anat.   and  physiol.,   1906,  xl,  189.     Med.  Chir.  Trans.,  1904, 

Ixxxvii,  403.     Brit.  Med.  Jour.,  1904,  ii,  62. 
Wallace:  British  Med.  Jour.,  1904,  ii,  62. 
Young,  H.  H.:  Quoted  by  Lowsley,  Jour.  Amer.  Med.  Assn.,  1913,  Ix,  no. 


CHAPTER  III 
PHYSIOLOGY 

In  describing  the  anatomy  of  the  prostate  gland  we  purposely 
omitted  that  detailed  description  of  the  urethra  and  urinary  bladder 
which  is  necessary  for  a  clear  understanding  of  the  physiological 
functions  of  these  parts.  The  ancient  view  that  the  prostate  gland 
took  an  active  part  in  the  act  of  urination  is  no  longer  tenable.  Never- 
theless the  bladder  and  proximal  urethra  are  so  closely  associated 
anatomically  with  the  prostate,  and  the  successful  surgery  of  pros- 
tatic enlargement  is  so  largely  dependent  upon  the  preservation  or 
restoration  of  normal  urinary  function,  that  the  anatomy  and  physi- 
logy  of  the  lower  urinary  tract  are  worthy  subjects  for  intimate 
study. 

Structure  of  the  Bladder  and  Urethra.^ — The  bladder  is  a  muscular 
sac  lined  with  a  mucous  membrane  and  covered  on  its  upper  surface 
with  peritoneum.  A  thin  layer  of  connective  tissue  uniting  the 
mucous  membrane  to  the  underlying  muscle  coats  constitutes  a  sub- 
mucous stratum. 

The  mucous  coat  consists  of  several  layers  of  transitional  epi- 
thelium resting  upon  a  fibro-elastic  tunica  propria.  It  presents 
marked  variations  in  thickness,  being  quite  thin  over  the  vesical 
trigonum ;  when  the  bladder  is  fully  distended  it  measures  only  about 
.1  mm.  In  the  empty  bladder,  the  smooth  trigonal  mucosa  of  the 
distended  viscus  is  thrown  into  longitudinal  folds;  under  these  circum- 
stances the  mucosa  may  attain  a  thickness  of  2  mm.  or  even  more. 
The  trigonal  glands  to  which  Waldeyer,  Kolischer  and  others  called 
attention,  and  which  Lowsley  has  described  at  some  length,  are  con- 
sidered by  Piersol  to  be  merely  tubular  depressions  and  not  true 
glands  at  all.  Young  and  others  have,  however,  described  peduncu- 
lated tumors  taking  origin  from  glandular  structures  situated  in  the 
trigonal  mucosa. 

The  submucous  coat  is  so  designed  as  to  permit  free  movement  of 
the  mucous  membrane  on  the  underlying  muscular  wall.  It  is  a 
loosely  woven  substance  composed  for  the  most  part  of  fibrous  tissue 
interwoven  with  elastic  fibres  which  are  not  easily  separated  from  the 
mucous  and  the  muscular  coats. 

61 


62  Physiology 

The  submucosa  is  wanting  in  the  trigonal  area,  hence  the  mucosa  is 
more  fixed  at  this  point  than  elsewhere. 

The  blood  vessels  and  nerve  plexuses  are  found  in  the  submucosa. 
The  muscles  of  the  bladder  wall  are  involuntary  in  type  and  are 
arranged  in  three  layers,  viz. — a  thin  outer  longitudinal,  a  thick 
middle  circular,  and  an  incomplete  inner  longitudinal  layer.  The 
muscular  coat  is  robust  and  in  a  contracted  state  of  the  bladder 
measures  about  i  cm.  in  thickness.  Enormous  hypertrophic  thicken- 
ing of  the  musculature  occurs  in  certain  cases  where  the  bladder  is  ob- 
structed and  infected.  When  the  bladder  is  distended,  the  musculature 
is  proportionately  thinned  out.  The  outer  longitudinal  layer  of  fibres 
is  most  prominent  on  the  upper  and  lower  surface  of  the  viscus.  This 
layer  is  not  complete,  the  spaces  between  the  individual  bundles  of 
fibres  being  filled  in  with  connective  tissue.  These  interfascicular  spaces 
constitute  points  of  weakness  in  the  bladder  wall  through  which  the 
mucosa  may  herniate,  and  when  there  is  an  obstruction  at  the  vesical 
outlet  or  in  the  urethra  result  in  acquired  diverticula. 

Muscle  fibres  from  the  outer  layer  are  continued  anteriorly  to  the 
body  of  the  pubic  bone,  constituting  the  pubo-vesical  muscle;  poste- 
riorly the  rectum  is  attached  to  the  bladder  by  fibres  extending  from 
the  anterior  layer — the  recto-vesical  muscle. 

The  circular  layer  is  the  best  developed  and  the  strongest  of  the 
three  layers  of  muscles  above  the  level  of  the  urethral  orifice;  below 
this  point  the  circular  layer  is  imperfect  so  that  the  trigonal  area  re- 
ceives few  fibres  from  this  layer. 

The  inner  longitudinal  muscle  coat  is  well  developed  in  the  region 
of  the  trigonum.  Elsewhere  it  is  composed  of  indefinite  and  indis- 
tinct groups  of  fibres  blended  with  the  connective  tissue  of  the  sub- 
mucosa. At  the  apex  of  the  trigonum  the  muscle  fibres  of  this  layer 
are  condensed  and,  in  conjunction  with  fibres  contributed  by  the 
proximal  portion  of  the  urethra,  form  the  internal  vesical  sphincter. 

Descriptions  of  the  muscular  structures  in  the  region  of  the  vesical 
outlet  are  likely  to  be  confusing  because  of  the  intimate  relationship  of 
the  vesical,  the  urethral,  and  the  prostatic  musculature.  The  proximal 
two-thirds  of  the  prostatic  urethra  is  derived,  as  is  also  the  trigonal 
area  of  the  bladder,  from  the  cloaco-allantois,  while  the  prostate 
gland  forms  from  tubular  evaginations  from  the  primitive  urethra, 
which  invade  the  undifferentiated  mesoblastic  tissues  surrounding  the, 
as  yet,  undeveloped  urethra.  This  mesoblastic  tissue  later  gives 
origin  to  the  intrinsic  musculature  of  the  prostatic  urethra  and  to  the 


Bladder  and  Urethra  63 

prostatic  stroma.  A  close  association  betweeen  these  structures 
continues  to  exist  in  the  adult. 

The  intrinsic  musculature  of  the  male  urethra,  involuntary  in 
type,  is  directly  incorporated  with  the  walls  of  the  canal.  It  is  divided 
into  two  layers,,  the  internal  longitudinal  layer  and  the  robust  external 
circular  layer.  The  internal  layer  is  continuous  with  the  internal 
longitudinal  muscle  layer  of  the  bladder,  and  extends  forward  to  the 
openings  of  Cowper's  ducts.  The  circular  muscular  coat  of  the  ure- 
thra is  in  intimate  relationship  with  the  internal  vesical  sphincter, 
although  the  latter  is  in  reality  derived  from  the  middle  muscular 
layer  of  the  trigonum.  Muscular  fibres  within  the  capsule  of  the 
prostate  gland  intermingle  with  the  fibres  composing  the  circular  coat 
of  the  proximal  urethra,  so  that  there  is  no  sharp  line  of  differentiation 
between  the  two  sets  of  fibres.  The  circular  coat  is  best  developed 
near  the  vesical  orifice  gradually  diminishing  in  thickness  as  it  extends 
forward  as  far  as  the  termination  of  the  membranous  urethra. 

The  musculature  surrounding  the  prostatic  ducts  is  likewise  inti- 
mately associated  with  the  circular  muscle  coat  of  the  urethra.  In  the 
removal  of  an  adenomatous  prostate  by  the  suprapubic  route  the 
musculature  of  the  proximal  urethra  can  hardly  escape  injury,  but 
the  internal  sphincter  is  preserved  because  it  has  become  displaced 
outward  by  the  invaginating  tumor.  In  some  instances  the  tumor 
mass  pushes  at  least  a  portion  of  the  fibres  of  the  sphincter  ahead  of 
it,  so  that  they  are  liable  to  injury  during  the  enucleation  of  the  tumor. 
A  groove  formed  on  the  surface  of  the  tumor  mass  denotes  the  line  of 
separation  between  the  intra-vesical  and  the  extra-vesical  portions  of 
the  mass,  and  marks  the  points  of  contact  of  the  internal  vesical  sphinc- 
ter and  the  margin  of  the  prostatic  sheath.  The  latter  is  deficient  in 
the  neighborhood  of  the  urethro-vesical  junction. 

The  extrinsic  muscles  of  the  urethra  are  important  factors  in  the 
physiology  of  urination  and  ejaculation.  The  compressor  urethrae 
muscle,  which  is  contained  between  the  layers  of  the  triangular  hgament 
within  the  deep  perineal  interspaces,  passes  from  side  to  side  and  encir- 
cles the  membranous  portion  of  the  urethra.  It  is  a  voluntary  muscle 
which  maintains  itself  in  a  state  of  tonic  contraction.  Its  nerve  supply 
is  derived  from  the  internal  pubic,  which  also  supplies  the  remaining 
extrinsic  muscles  of  the  urethra. 

Continuous  with  this  muscle  above,  and  considered  by  some  to  be 
a  part  of  it,  is  the  external  vesical  sphincter.  The  latter  muscle  com- 
prises encircling  bundles  of  striped  muscle  fibres  which  surround  the 


64  Physiology 

urethra  at  the  apex  of  the  prostate  and  are  intimately  associated,  not 
only  with  the  sheath  and  the  musculature  stroma  of  the  gland,  but  also 
with  the  pelvic  fascia,  which  at  this  point  stretches  between  the  pelvic 
rami  to  form  the  deep  layer  of  the  triangular  ligament.  Above  the 
external  vesical  sphincter,  the  extrinsic  muscle  fibres  lie  entirely  in 
front  of  the  urethra. 

Although  the  external  vesical  sphincter  is  normally  held  in  a  state 
of  tonic  contraction  the  strength  of  its  contractions  may  be  increased 
by  the  influence  of  the  will. 

The  nerves  of  the  bladder  and  of  the  prostatic  urethra  comprise 
both  sympathetic  and  spinal  fibres;  they  are  connected  with  the  cord, 
as  are  also  the  nerves  of  the  prostate  gland,  by  means  of  the  hypogas- 
tric plexus.  From  the  latter  the  nerve  fibres  take  two  courses,  one  to 
the  sacral  cord  by  way  of  the  N.  erigens,  the  other  to  the  lumbar  cord 
through  the  N.  hypogastricus.  The  majority  of  the  fibres  from  the 
sacral  cord  are  carried  in  the  ventral  branches  of  the  second,  third,  and 
fourth  sacral  nerves. 

The  spinal  fibres  are  distributed  chiefly  to  the  trigonal  and  urethral 
regions  of  the  bladder,  by  far  the  most  sensitive  portions  of  the  viscus. 
The  sympathetic  fibres,  which  go  to  the  muscles,  follow  the  blood  ves- 
sels and  break  up  into  fine  strings  which  end  in  microscopic  ganglia. 
Some  of  the  terminals  are  found  in  the  substance  of  the  muscle,  while 
others  penetrate  the  submucosa  and  terminate  in  ganglia  which  lie 
between  the  epithelial  cells  of  the  mucosa. 

The  urinary  function  is  presided  over  by  a  centre  or  centres  in  the 
lumbar  cord  which  in  turn  are  connected  with  higher  centres  all  the 
way  to  the  brain  cortex.  The  fibres  are  said  to  cross  at  the  level  of 
the  fifth  lumbar  nerve,  and  a  second  crossing  is  said  by  Langley  and 
Anderson  to  occur  in  the  inferior  mesenteric  ganglia.  Various  centres 
in  the  cerebral  cortex  have  been  described,  and  it  has  been  shown  that 
stimulation  of  any  sensory  nerve  or  of  any  part  of  the  spinal  cord  will 
cause  contraction  of  the  bladder  muscles. 

The  bladder,  the  prostate,  the  seminal  vesicles,  and  the  prostatic 
urethra  derive  arterial  branches  from  the  inferior  vesical  and  middle 
hemorrhoidal  arteries;  the  bladder  in  addition  is  supplied  by  the 
superior  vesical  artery,  a  branch  of  the  internal  iliac  artery,  and  by 
branches  from  the  internal  pudic  and  obturator  arteries.  These 
structures  are  drained  by  veins  which  pass  into  the  large  prostatico- 
vesical  plexus  at  the  sides  of  the  bladder  and  thence  into  the  internal 
iliac  veins. 


Urination 


65 


The  lymphatics  of  the  bladder  begin  within  the  muscular  coat 
through  which  they  pass  and  collect  to  form  a  subperitoneal  plexus. 
Efferent  lymph  channels  pass,  in  company  with  the  arteries,  upward 
from  the  fundus  and  downward  from  the  apex  or  body  of  the  bladder 
and  eventually  drain  into  the  internal  iliac  nodes  and  nodes  situated 
at  the  bifurcation  of  the  aorta.  The  majority  of  the  prostatic  lymph- 
atics are  also  tributaries  of  the  internal  ihac  group  of  nodes,  but  some  of 
them  drain  into  the  obturator  nodes  of  the  pelvic  wall. 

The  Physiology  of  Urination.— Under  normal  conditions  the  urine 
is  retained  within  the  bladder  cavity  by  the  action  of  the  internal 
vesical  sphincter.  No  matter  how  great  the  desire  to  empty  the  bladder 
may  be,  the  muscle  does  not  relax  until  the  act  of  urination  is  begun; 
the  deep  urethra  does  not,  as  was  formerly  supposed,  become  a  part  of 
the  bladder  cavity  when  the  latter  viscus  is  distended.  (This  ancient 
belief  is  now  discarded;  indeed  the  results  of  experiments  undertaken  to 
prove  the  correctness  of  this  theory  have  been  shown  to  have  been 
wrongly  interpreted.)  The  contention  of  Finger  and  of  Oppenheim 
that  the  fully  distended  bladder  is  pear-shaped  because  of  the  inclusion 
of  the  deep  urethra  in  the  bladder  cavity,  was  first  refuted  by  von 
Zeissl  whose  arguments  were  based  on  the  study  of  cystograms.  Since 
the  publication  of  von  Zeissl's  observations,  a  host  of  other  authors 
have  confirmed  his  findings,  and  at  the  present  time  it  is  a  generally 
accepted  fact  that  the  internal  vesical  sphincter  retains  the  urine  in  all 
normal  circumstances.  In  the  presence  of  long-standing  obstruction 
in  the  membranous  urethra  the  parts  proximal  to  it  may  become 
dilated  so  that  eventually  the  internal  sphincter  may  become  perma- 
nently inadequate  to  retain  the  urine,  but  in  normal  individuals  it  is  the 
internal  sphincter  alone  which  closes  the  bladder  Normally  the  length 
of  catheter  necessary  to  draw  the  urine  is  the  same  whether  the  bladder 
is  fully  distended  or  comparatively  empty.  This  would  obviously  not 
be  the  case  if  the  prostatic  urethra  became  continuous  with  the  bladder 
cavity  in  a  state  of  marked  urinary  distention.  In  some  instances  the 
internal  vesical  orifice  is  held  open  by  an  invading  prostatic  nodule 
which  prevents  the  sphincter  muscle  from  functioning  normaUy.  Under 
these  circumstances  the  deep  urethra  may  become  continuous  with  the 
bladder  cavity,  and  either  incontinence  results  or  the  urine  is  retained 
within  the  prostatic  urethra  and  the  bladder  by  the  action  of  the  ex- 
ternal sphincter  muscle. 

The  final  proof  controverting  Finger's  theory  came  with  cystographic 
demonstrations  that  the  distended  normal  bladder  is  an  oval  or  rounded 


66  Physiology 

structure  in  which  there  is  no  suggestion  of  a  vesical  neck.  Inconti- 
nence of  urine  following  prostatectomy  usually  means  injury  to  both 
sphincters.  Normally  the  internal  sphincter  muscle  is  held  in  a  state 
of  tonic  contraction  under  the  control  of  the  hypogastric  nerves.  The 
urine  accumulates,  distending  the  bladder  and  putting  the  detrusor 
muscle  on  the  stretch.  The  latter  muscle  contracts  rhythmically  sending 
impulses  to  the  cord  and  thence  to  the  brain  where  they  are  translated 
into  a  conscious  desire  to  void.  The  inhibitory  influences  of  the  spinal 
centre,  which  latter  maintains  the  tone  of  the  internal  sphincter,  is 
removed  and  the  muscle  relaxes.  Synchronous  with  this  relaxation, 
the  detrusor  muscle  is  stimulated  to  greater  activity  and,  together 
with  voluntary  contractions  of  the  abdominal  muscles,  elevates  the 
intravesical  pressure  and  the  urine  is  caused  to  flow  with  rapidity  into 
the  urethra.  Thereafter  the  act  is  continued  reflexly  probably  as  the 
result  of  stimuli  which  arise  from  contact  of  the  urine  with  the  urethral 
mucosa;  the  act,  however,  is  under  the  control  of  the  will  and  the  reflex 
action  is  always  subject  to  intrusions  of  cerebral  influence. 

The  prostatic  gland  is  entirely  passive  during  the  act  of  urination 
which  is  a  function  of  the  neuro-muscular  system  of  the  bladder  and 
the  urethra. 

The  Physiology  of  Ejaculation. — The  sexual  orgasm  is  essentially  a 
reflex  action  the  centre  being  located  in  the  lumbo-sacral  region  of  the 
cord.  The  reflex  is  maintained  after  transverse  section  of  the  cord 
above  this  level.  According  to  Miiller,  only  the  lower  part  of  the  cord 
need  be  retained  in  order  to  preserve  the  erection  reflex.  The  afferent 
nerve  fibres  to  the  penis,  and  probably  also  to  the  prostate  and  the 
vesicles  as  well  as  the  bladder  are  carried  in  the  nervi  erigentes  and 
hypogastrics.  Eckhard  was  the  first  to  show  that  the  penis  of  the  dog 
could  be  erected  experimentally  by  stimiilation  of  the  nervi  erigentes 
which  come  from  the  first  and  second  sacral  and  sometimes  also  from 
the  third  sacral  nerves. 

The  orgasm  results  from  the  reflex  discharge  of  erector  impulses 
which  follow  one  or  more  fixed  pathways  from  the  erector  centre  in  the 
spinal  cord.  The  afferent  impulses  are  brought  to  the  cord  along 
widely  different  pathways.  Erection  and  even  ejaculation  can  be 
induced  voluntarily  by  stimuli  conveyed  from  the  brain.  In  the 
treatment  of  abnormalities  of  the  sexual  function  supposedly  dependent 
upon  pathologic  processes  in  the  sexual  glands,  the  physician  will  do 
well  to  bear  in  mind  the  psychologic  factors  involved  in  so  complex 
a  physiologic  process. 


Prostate   Gland  67 

The  emission  of  the  semen,  which  in  the  male  marks  the  culmination 
of  the  sexual  impulse,  denotes  the  termination  of  a  series  of  muscular 
contractions;  these  are  said  to  begin  in  the  walls  of  the  vasa  efferentia 
of  the  testicles  and  to  pass  to  the  canal  of  the  epididymis  and  thence 
along  the  vasa  deferentia.  The  vesiculas  seminales  contract  simul- 
taneously expeUing  their  contents  into  the  vasa,  and  the  mixed  fluid 
passes  out  through  the  ejaculatory  ducts  into  the  prostatic  urethra. 
The  prostatic  muscles  contract  at  the  same  time  and  in  addition  to 
expelHng  the  secretion  of  the  prostate  also  assist  in  emptying  the  ejacu- 
latory ducts.  The  final  discharge  of  semen  from  the  urethra  is  brought 
about  by  rhythmic  contractions  of  the  intrinsic  and  extrinsic  muscles 
of  the  canal. 

In  describing  the  innervation  of  the  prostate  gland  attention  was 
called  to  the  fact  that  this  gland  receives  two  sets  of  nerve  fibres:  one 
from  the  nervi  erigentes  which  are  purely  motor,  the  other  through  the 
hypogastrics  which  are  mixed  nerves.  Stimulation  of  the  nervi  erigen- 
tes will  cause  contraction  of  the  prostatic  musculature  and  the  expulsion 
of  prostatic  fluid  into  the  urethra.  Loeb,  by  stimulation  of  the  hypo- 
gastric nerves,  also  obtained  contractions  of  these  muscles  as  well  as 
increased  secretory  activity  on  the  part  of  the  glandular  epithelium. 
Contractions  of  the  muscles  of  the  seminal  vesicles  and  the  vasa  defer- 
entia are  said  to  follow  stimulation  of  the  hypogastric  nerve. 

Langley  and  Anderson  have  shown  that  the  internal  generative 
organs  of  the  cat  and  the  dog  are  supplied  by  fibres  running  in  the 
anterior  tracts  of  the  second,  third,  fourth,  and  fifth  lumbar  nerves  and 
thence  by  way  of  the  hypogastrics.  Stimulation  of  these  nerves  causes 
strong  contractions  of  the  musculature  of  the  vasa  deferentia  and  uterus 
masculinus;  the  contractions  being  strong  enough  to  produce  the  emis- 
sion of  semen  from  the  urethra. 

Marshall  calls  attention  to  the  fact  that  the  ejaculation  of  semen 
is  of  some  complexity  involving  more  than  one  centre  in  the  spinal  cord. 
He  is  of  the  opinion  that  the  centre  for  the  final  expulsion  of  semen  must 
be  the  same  as  that  for  erection  since  the  muscular  mechanisms  con- 
cerned are  to  a  large  extent  the  same.  The  contractions  of  the  prostatic 
musculature  are  governed  by  the  same  spinal  centres  and  the  same 
nerve  tracts. 

The  Physiology  of  the  Prostate  Gland. — The  chief  function  of  the 
prostate  gland  is  to  furnish  a  liquid  medium  chemically  and  physio- 
logically suitable  to  the  needs  of  the  spermatoza  in  their  passage  from 
the  genital  glands.     Whether  it  is  an  inert  medium  or  one  without 


68  Physiology 

which  the  spermatozoa  could  not  function  normally,  is  not  definitely 
known.  Fiirbinger  and  Kolliker  were  the  first  to  maintain  that  the 
prostatic  fluid  has  a  stimulating  effect  on  the  motility  of  the  sperma- 
tozoa. Steinach  contributed  the  observation  that  prostatic  fluid  when 
added  to  the  spermatozoa  suspended  in  normal  saline  solution  prolongs 
their  lives.  Iwanoff,  on  the  contrary,  has  shown  that  Spermatozoa 
uninfluenced  by  prostatic  fluid  are  capable  of  fecundation,  while  a 
host  of  other  writers  attest  the  activity  of  sperm  derived  directly  from 
the  testicles  by  aspiration.  These  observations  would  seem  to  indicate 
that  the  prostatic  fluid  is  not  vitally  important  to  the  spermatozoa. 

Testicular  fluid  is  alkaline  in  reaction,  and  as  pointed  out  by 
Adams,  that  of  the  prostate  is  acid  in  reaction,  hence  it  may  be  in- 
ferred that  the  prostatic  fluid  has  an  important  neutralizing  effect  on 
the  testicular  secretion.  Fiirbinger  has  shown  that  excessive  amounts 
of  prostatic  fluid  have  a  lethal  effect  on  spermatozoa.  Steinach, 
moreover,  has  demonstrated  that  removal  of  the  seminal  vesicles  and 
the  prostate  gland  from  white  rats,  while  not  diminishing  the  sexual 
passion  and  the  ability  to  perform  the  sexual  act,  including  the 
actual  discharge  of  spermatozoa,  prevents  entirely  the  fertilization  of 
the  ova;  removal  of  the  seminal  vesicles  alone  markedly  weakens  the 
fertilizing  power  of  the  semen. 

It  is  not  known  whether  the  prostate  furnishes  an  internal  secretion 
to  the  body;  that  it  furnishes  one  of  any  considerable  consequence  is 
at  all  events  unlikely. 

Serrallach  and  Pares  have  contributed  the  results  of  experimental 
work  indicating  that  the  prostate  secretes  an  internal  secretion  which 
controls  the  testicular  functions  and  regulates  the  process  of  ejacu- 
lation. It  is  stated  that  removal  of  the  prostate  causes  spermato- 
genesis to  cease,  and  causes  also  a  cessation  of  the  secretory  activity 
of  the  accessory  sexual  glands.  The  results  of  these  experiments 
have  not  been  enthusiastically  supported.  That  there  is  a  close 
physiological  relationship  between  the  secretory  activities  of  the 
several  genital  glands  is  not  to  be  questioned,  and  it  is  reasonable  to 
suppose  that  internal  secretions  are  the  media  of  control;  that  the 
most  important  internal  secretion  is  of  prostatic  origin  is,  however, 
extremely  unlikely. 

Macht  has  reported  some  highly  interesting  observations  on  the 
influence  of  dessicated  prostatic  substance  on  the  growth  and  develop- 
ment of  tadpoles,  which  seem  to  indicate  the  presence  of  an  internal 
prostatic  secretion. 


Prostatic   Secretion  69 

Various  tadpoles  were  fed  with  prostatic  tissue  obtained  from 
human  operative  specimens  as  well  as  from  certain  of  the  lower  animals 
and  the  results  were  controlled  by  comparing  them  with  the  effect  on 
other  tadpoles  with  various  other  glandular  substances.  The  results 
of  feeding  with  prostatic  tissue,  which  were  striking,  manifested  them- 
selves not  only  in  stimulating  normal  growth  and  differentiation  of  the 
larvae,  but,  what  seems  to  us  of  more  significance,  in  stimulating 
growth  to  a  size  above  that  which  is  normal.  Macht  draws'  the 
following  conclusions  from  his  work: 

(a)  "It  was  found  that  prostatic  tissue  feeding  tended  to  stimulate 
both  the  growth  and  metamorphosis  of  the  larvas  of  the  frog,  toad 
and  salamander. 

(b)  These  observations  speak  in  favor  of  an  internal  secretion  of 
the  prostate  gland." 

Griffith  has  shown  that  the  prostate  gland  in  the  hedgehog  under- 
goes definite  cyclical  changes.  In  both  man  and  animals  the  growth 
and  development  of  the  prostate  gland  would  seem  to  depend  upon 
the  maturation  of  the  cells  lining  the  seminiferous  tubules,  since  full 
development  occurs  only  after  the  establishment  of  puberty.  It  will 
be  recalled  that  the  operation  of  double  castration  for  the  cure  of 
prostatic  hypertrophy  was  based  on  the  theory  that  the  abnormal 
growth  was  dependent  upon  an  internal  secretion  supplied  by  the  tes- 
tes. Atrophy  of  the  normal  prostate  occurs  after  castration  in  patients 
who  have  passed  the  age  of  puberty.  Much  experimental  evidence 
has  accumulated  which  proves  that  this  function  of  the  testes  is  inde- 
pendent of  its  spermatogenic  function.  Familiar  clinical  examples 
are  found  in  cases  of  cryptorchidism  in  which  normal  prostatic  devel- 
opment has  taken  place  and  in  which  the  secondary  sexual  character- 
istics have  developed  normally  with  unimpaired  sexual  potency  in  the 
complete  absence  of  spermatogenesis.  The  sterihty  caused  by  ic-rays 
is  due  to  the  specific  action  of  the  rays  on  the  spermatogenic  cells;  the 
cells  of  internal  secretion  are  not  affected  by  them. 

That  there  is  an  internal  secretion  elaborated  by  the  prostate 
gland,  the  function  of  which  is  to  stimulate  spermatogenesis,  is  ex- 
tremely doubtful. 

The  Prostatic  Secretion.^The  normal  prostatic  fluid  is  a  thin 
opalescent  fluid  containing  numerous  minute,  round,  homogenous 
bodies,  lecithin,  a  few  large  granular  elements,  and  a  moderate  number 
of  leucocytes  and  round  and  columnar  epithelial  cells. 

According   to  Gley  and  Camus,  the  prostatic  secretion  contains 


70  *  Physiology 

a  ferment,  vesiculose,  the  action  of  which  causes  clotting  of  the  seminal 
fluid.  In  certain  rodents  the  seminal  clotting  is  said  to  be  for  the 
purpose  of  preventing  the  escape  of  the  spermatozoa  from  the  female 
passages,  thus  helping  to  ensure  fertilization. 

Lataste  was  the  first  to  call  attention  to  the  clotting  of  seminal 
fluid  within  the  female  passages  and  refers  in  his  writings  to  the  clotted 
seminal  fluid  as  the  "bouchon  vaginal"  the  formation  of  which  is  now 
attributed  to  a  ferment  elaborated  by  the  prostatic  cells. 

The  prostatic  secretion  is  alkaline  to  litmus  and  acid  to  phenol- 
phthalein.  According  to  Fiirbinger,  it  contains  spermine,  which  when 
brought  into  contact  with  the  phosphates  secreted  by  the  other  genital 
glands  produces  Bottcher's  crystals.  Concretions  are  frequently  found 
in  the  prostatic  acini  in  advanced  life  and  also  sometimes  in  the  prostates 
of  young  men.  These  concretions,  or  corpora  amylacea,  occur  also  in 
the  alveoli  of  the  lung.  Their  nucleus  is  probably  mucoid  material  and 
broken  down  epithelial  cells;  while  the  concentrically  arranged  layers 
of  prostatic  concretions  are  formed  either  by  the  stratified  accretion  of 
the  hyaUne  debris  of  cells  or  of  inspissated  prostatic  secretion.  The 
amount  of  soKd  matter  in  corpora  amylacea  has  been  estimated  at  from 
46  to  86  per  cent.  The  prostatic  fluid  contains  only  about  1.5  per  cent. 
soUds  which  are  mostly  proteids  and  salts. 

REFERENCES  (CHAPTER  in) 

Barringer  and  MacKee:  Radiographs  of  the  Bladder  and  Bladder  Neck.     Trans.  Amer. 

Urol.  Assoc,  191 2,  vi,  408. 
De  Bonis,  W.:  Ueber  Sekreticnserscheinungen  in  den  Driisenzellen  der  Prostata.     Arch.  f. 

Anat.  u.  Phys.,  1907,  Anat.  Abt.,  i. 
Eckhard:  Beitr.  zur  Anat.  und  Physiol.,  1863,  iii. 
Finger:  All.  Wien.  med.  Ztschr.,  1893,  xxxviii,  427;  439;  452. 

Fischel  and  Kreelich:  Ueber  Prostata  Sekretion,  Wien.  klin.  Wchnschr.,  191  r,  xxiv,  901. 
Frankl-Hochwart  and  Zuckerkandl:  Die  nervosen  Erkrankungen  der  Blase.     Nothnagels 

spez.  Path.  u.  Ther.,  1898,  Bd.  19. 
Fiirbringer:  Nothnagel's  Pathologie  u.  Therapie,  1895,  xix;  Berliner  kb"n.  Woch.,  1886, 

xxiii,  476. 
Gley  and  Camus:  C.  R.  de  Soc.  de  Biol.,  1897,  iv,  787. 

Griffith:  Jour.  Anat.  and  Physiol.,  1888,  xxiii,  374;  Ibid.,  1889,  xxiv,  27;  236. 
Guyon:  Physiologie  de  la  Vesic,  Gaz.  Hebdom.  de  Med.  et  Chir.,  1884.  Physiologic  der 

Retentio  urinse,  Zentrabl.  fiir  die  Krankheiten  der  Ham  und  Sexual  Organe,  1890,  ii,  7. 
Hada  and   Gotzel:  Wechselbeziehungen  zwischen  Hoden  u.    Prostata.     Prager.  med. 

Wochnschr.,  1914,  xxxix,  433. 
Hyman:  Ann.  Surg.,  1914,  iix,  544;  Med.  Record,  1918,  xciv,  610. 
Isihara,  M.:  Ueber  das  Lipoidpigment  der  Prostatadriisen.     Folia  Urol.,  1915,  ix,  280. 
Iwanoflf:  Jour,  de  Phys.  et  de  Path.,  Gen.,  1900,  ii,  95. 
Iwanow  and  Andrew:  Recherches  sur  les  fragments  de  la  liquide  spermatique  du  chien. 

Compt.  rend.  Soc.  de  Biol.,  1916,  Lxxix,  85. 


References 


71 


Kolischer:  Quoted  by  Piersol. 

Kolliker:  Zeitschr.  f.  wiss.  Zool.,  1856,  vii. 

Langley  and  Anderson:  Jour,  of  Physiol.,  1891.  xii;  Ibid.,  1895,  xix,  71. 

Lataste:  Zool.  An.,  1883,  vi. 

Launois:  Annal.  d.  Mai.  d.  org.  gen.-urin.,  1894,  xii,  721. 

Leedham- Green:  British  Med.  Jour.,  1906,  ii,  297. 

Legueu  and  Gaillardot:  Toxicity  g^n^rale  des  extraits  de  la  prostate  hypertrophie.     Jour. 

d'urol.,  191 2,  ii,  50. 
Loeb:  Inaug.  Dissert.,  Giessen,  1866. 

Lowsley:  Jour.  Amer.  Med.  Assn.,  1913,  Ix,  no;  Medical  Record,  1915,  Ixxxviii,  383. 
Macht,  D.  I.:  Physiological  and  Pharmacological  Studies  of  the  Prostate  Gland.     Jour. 

of  Urolog.,  1920,  iv,  115. 
Marx;  M.:  Quelques  consideration  sur  I'hyper trophic  de  la  prostate  au  point  de  vue 

genital.     Gaz.  m€d.  de  Paris,  1915,  Ixxxvi,  21. 
Oppenheim  and  Loew:  Der  Mechanismus  des  Blasenverschlusses  im  Rontgenbild,  Centralbl. 

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Porosz:  Archiv.  f.  Anat.  u.  Physiol.  Anat.,  Leipzig,  1913,  Anat.  Abt.,  (Supplement-bd.)  172. 
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90. 
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CHAPTER  IV 

ETIOLOGY  AND  PREDETERMINING  FACTORS  OF  BENIGN 
PROSTATIC  HYPERTROPHY 

Etiology. — We  are  tempted  to  dismiss  the  subject  of  the  etiology  of 
benign  prostatic  enlargement  as  did  that  most  experienced  of  all 
modern  prostatectomists,  Mr.  Freyer  of  London,  by  confessing  our 
complete  ignorance  of  the  cause  of  the  condition. 

It  is  undoubtedly  true  that  but  little  has  been  added  to  our  knowl- 
edge of  the  etiology  of  prostatic  hypertrophy  within  the  past  fifty 
years;  certainly  the  true  cause  or  causes  of  the  adenomatous  form  of 
the  disease  have  not  been  demonstrated. 

Careful  statistical  studies  of  large  series  of  cases  and  of  specimens 
removed  at  operation  which  would,  it  was  hoped,  throw  some  light  on 
the  etiology  of  the  disease  have  failed  to  reveal  the  exciting  cause  of 
prostatic  hypertrophy.  Indeed,  the  most  diverse  views  are  held  re- 
garding the  anatomical  characteristics  of  the  disease.  Yet  practically 
everyone  is  agreed  that  there  do  exist  two  main  pathologic  types  of 
benign  enlargement  of  the  prostate  which  give  rise  to  urinary  obstruc- 
tion in  men  past  the  age  of  fifty  years:  one  in  which  there  is  a  dis- 
proportionate increase  in  the  size  of  the  prostate  due  to  the  formation 
within  the  organ  of  tumor-like  masses  which  are  composed  of  tissue 
whose  elemental  structure  is  identical  with  that  of  the  normal  prostate, 
and  a  second  type  in  which  there  is  a  disproportionate  increase  in  the 
fibrous  tissue  content  of  the  prostate  which  sometimes  causes  an  increase 
in  the  size  of  the  gland,  while  in  other  instances  it  is  either  not  enlarged 
or  is  actually  smaller  than  normal.  The  latter  type  was  at  one  time 
looked  upon  as  an  end-product  in  the  pathologic  evolution  of  the  adeno- 
matous prostate  but  there  is  very  little  doubt  among  the  majority  of 
pathologists  that  the  two  processes  are  separate  and  distinct,  the  one 
being  in  all  probability  a  true  tumor  disease  whose  etiology  is  shrouded 
in  that  same  mystery  which  envelopes  neoplastic  diseases  as  a  class, 
the  other  consequent  upon  inflammation,  usually  bacterial  in  origin. 
The  factors  that  predetermine  bacterial  growth  in  the  prostate  may 
not  differ  from  causes  that  predispose  to  tumor  formation  in  this 
organ.  To  further  complicate  matters  the  two  types  of  disease  often 
coexist  in  the  same  prostate  each  adding  its  influence  to  the  production 

72 


Tumor   Theory  73 

of  urinary  obstruction.  The  inflammatory  lesion  is,  we  believe,  fre- 
quently engrafted  on  a  prostate  already  the  seat  of  a  neoplasm,  for 
here  as  elsewhere  tumors  are  prone  to  become  secondarily  infected. 

It  must  not  be  supposed  that  all  benign  diseases  of  the  prostate 
gland  causing  urinary  obstruction  are  easily  divisible  into  the  foregoing 
types.  Examples  are  frequently  met  with  in  which  neither  adeno- 
matous tissue  nor  fibroblastic  elements  are  recognizable  and  the  pros- 
tate which  is  small  and  indurated  is  found  on  minute  examination  to 
consist  largely  of  fibromuscular  stroma  which  has  become  increased, 
often  to  a  marked  extent,  at  the  expense  of  the  secreting  structure. 
The  condition  is  obviously  not  a  true  hypertrophy,  neither  is  it  neoplas- 
tic or  inflammatory  in  nature.  Personally  we  beHeve  that,  excepting 
those  cases  presenting  the  fibroblastic  evidence  of  true  chronic  inflamma- 
tion, all  cases  of  benign  senile  erflargement  of  the  prostate  result  from 
some  perversion  in  the  normal  involution  of  the  gland.  The  fact  that 
a  mass  fulfilling  all  the  requirements  of  our  modern  definition  of  tumor 
is  found  in  certain  instances  is  due,  I  believe,  to  environmental 
influences. 

If  we  accept  the  tumor  theory  of  the  origin  of  the  adenomatous 
form  of  the  disease  it  is  encumbent  upon  us  to  discuss  at  some  length 
the  theories  of  tumor  genesis  in  general. 

This  subject  is  largely  of  academic  interest,  however,  and  one  un- 
suited  for  detailed  discussion  in  a  book  of  this  kind.  If  the  reader  is 
especially  interested  in  the  subject  he  is  advised  to  consult  the  chapter 
on  the  etiology  of  tumor  diseases  written  by  Professor  McFarland  for 
our  book,  "The  Breast,  Its  AnomaHes,  Its  Diseases  and  their  Treat- 
ment." 

To  those  who  adhere  to  the  inflammatory  theory,  the  etiology  both 
as  regards  the  exciting  cause  and  the  predetermining  factors  is  not  a 
matter  of  perplexity  because  the  varieties  of  bacteria  and  the  causes 
inviting  their  lodgment  and  development  in  the  prostate  gland  are 
well  known.  Ciechanowski  was  the  first,  and  now  oft-quoted,  advocate 
of  the  theory  of  antecedent  inflammation  as  the  cause  of  senile  prostatic 
enlargement.  According  to  this  writer,  the  modus  operandi  of  the 
inflammatory  factor  is  a  purely  mechanical  one,  the  initial  step  in  the 
process  being  chronic  inflammation  of  long  standing  with  scar  tissue 
formation  about  the  ducts  which  results,  secondarily,  in  dilatation 
of  the  glands. 

The  historical  evidence  for  or  against  infection  as  the  cause  of 
prostatic  enlargement  is  not  convincing,  nor  does  the  fact  that  AI- 


74  Etiology  and  Predetermining  Factors 

barran  found  microscopic  evidence  of  inflammation  in  all  of  one  hun- 
dred cases  of  hypertrophy  prove  conclusively  that  the  inflammation 
was  the  causative  factor  in  these  cases;  it  is  quite  as  probable  that  the 
round-cell  infiltration  which  he  found  in  association  with  the  enlarged 
prostate  was  caused  by  the  presence  within  the  organ  of  the  abnormal 
tissue. 

Among  the  more  recent  advocates  of  the  inflammatory  origin  of 
glandular  development  in  the  prostates  of  old  men  are  Wilson  and 
McGrath. 

There  is  no  doubt  that  inflammatory  changes  taking  place  in  the 
subcervical  group  of  glands  (Albarran's  glands)  will  lead  to  urinary 
obstruction  either  as  the  result  of  glandular  development  or  of  de- 
posit with  organization  of  inflammatory  exudate,  but  we  cannot 
believe  that  adenomatous  nodules  occurring  in  the  prostatic  lobes  are 
the  results  of  inflammatory  stimulation.  We  agree  with  Wilson  and 
McGrath  when  they  say  that  the  greater  part  of  the  bladder  troubles 
of  old  people  are  due  more  to  exacerbation  of  chronic  prostatitis 
than  to  hypertrophy,  but  we  cannot  agree  with  those  who  attribute  the 
formation  of  adenomatous  nodules  within  the  prostate  to  chronic 
inflammation. 

Many  clinicians  including  Rovsing,  Pilcher,  Young,  and  Keyes 
oppose  the  inflammatory  theory  basing  their  conclusions  on  the 
following  facts: 

The  usual  result  of  inflammation  is  atrophy  rather  than  hyper- 
trophy; many  patients  with  hypertrophy  of  the  prostate  never  had 
antecedent  inflammation  of  the  organ;  the  early  stages  of  hypertrophy 
have  no  constant  time  relationship  with  the  late  stages  of  gonorrhoea 
or  other  inflammatory  processes;  and  hypertrophic  processes  begin 
very  late  after  the  apparent  cure  of  an  antecedent  gonorrhoea. 

Lymphoid  hyperplasia  undoubtedly  exists  in  association  with  the 
hyperplastic  element  comprising  the  enlarged  prostate  in  a  large  per- 
centage of  cases,  but  the  inflammatory  element  is  probably  engrafted 
upon  a  pre-existing  hypertrophy  and  due  in  many  instances  to  primary 
degeneration  of  the  nodules  within  the  gland. 

Henry  Wade  has  offered  an  interesting  hypothesis  which  bases  the 
origin  of  benign  prostatic  enlargement  on  some  alteration  in  a  normal 
internal  secretion.  Wade  classifies  the  disease  as  inflammatory  in 
type  and  suggests  for  it  the  name  "chronic  lobular  prostatitis"  in  dif- 
ferentiation from  "chronic  interstitial  prostatitis,"  the  end-product  of 
which  is  the  sclerotic  gland. 


Tumor   Theory  75 

He  calls  attention  to  the  fact  that  senile  hyperplasia  occurs  in  both 
chronic  lobular  prostatitis  (hypertrophy)  and  chronic  cystic  mastitis 
(abnormal  involution).  The  term  chronic  lobular  prostatitis  is  just 
as  unfortunate  for  senile  enlargement  of  the  prostate  gland  as  is  the 
term  chronic  cystic  mastitis  when  applied  to  the  abnormal  involu- 
tionary  changes  that  occur  in  the  senile  breast.  In  neither  instance 
is  the  pathologic  evidence  supporting  the  inflammatory  theory 
sufficiently  clear  and  convincing;  in  neither  disease  does  fibroblastic 
proliferation  occur  with  sufficient  constancy  to  justify  the  assumption 
that  the  condition  is  an  inflammatory  one.  We  are  in  accord  with 
Wade  when  he  expresses  the  opinion  that  the  disease  is  probably 
due  to  the  abnormal  action  of  one  or  more  internal  secretions;  we 
entirely  disagree  with  him  when  he  employs  the  term  "chronic  lobular 
prostatitis"  to  imply  the  presence  of  inflammatory  products  in  the 
enlarged  prostate.  Wade  denies  the  neoplastic  nature  of  the  hyper- 
trophied  prostate.  It  is  entirely  probable  that  so-called  prostatic 
hypertrophy  begins  similarly  to  abnormal  involution  of  the  breast,  but 
owing  to  environmental  changes,  the  hyperplastic  areas  in  the  prostate 
become  transformed  into  more  or  less  discrete  circumscribed  nodules, 
which,  from  the  physical  characteristics  that  they  sooner  or  later  may 
present,  such  as  distinct  encapsulation,  may,  for  all  practical  purposes, 
be  looked  upon  as  tumors. 

Many  of  the  factors  that  are  now  considered  as  predetermining 
the  creation  of  the  sclerotic  prostate  were  once  considered  etiologic 
influences  in  the  development  of  the  hypertrophic  form  of  the  disease. 
These  factors,  which  include  errors  in  ahmentaion,  sexual  excesses  or 
irregularities,  febrile  diseases,  etc.  will  be  discussed  later. 

Velpeau  held  that  prostatic  hypertrophy  is  analagous  to  fibroid 
disease  of  the  uterus,  basing  the  analogy  on  a  supposed  common 
embryological  origin  of  the  two  organs. 

The  French  school  headed  by  Guyon  and  Lauriois  maintained  that 
prostatic  hypertrophy  is  a  local  manifestation  of  general  arterio- 
sclerosis. This  theory  lost  cast  when  it  was  demonstrated  that 
narrowing  and  obliteration  of  the  prostatic  arteries  is  rarely  found 
in  association  with  benign  senile  enlargement  of  the  gland. 

The  discarded  theory  of  Reginald  Harrison  who  regarded  the  en- 
largement of  the  prostate  as  compensatory  adjustment  of  a  disturbance 
in  the  mechanics  of  urination  caused  by  primary  descent  of  the  bladder 
floor,  has  been  resurrected  for  the  purpose  of  illustrating  how  indefinite 
our  views  were  regarding  the  condition  just  a  few  decades  ago. 


76  Etiology  and  Predetermining  Factors 

The  true  etiologic  factors  involved  in  simple  enlargement  of  the 
prostate  gland  will  probably  be  found  to  be  identical  with  those  giving 
rise  to  benign  neoplasms  and  abnormal  involution  of  the  senile  breast. 

Predetermining  Factors.— In  the  present  inexact  state  of  our  knowl- 
edge of  the  pathology  of  prostatic  enlargement,  it  is  impossible  to  speak 
authoritatively  on  the  factors  that  are  supposed  to  predispose  an 
individual  to  this  disease.  Obviously,  if  it 'becomes  an  established 
fact  that  the  enlargement  of  the  prostate  is  a  late  sequel  of  inflamma- 
tion and  that  we  are  really  dealing  with  a  form  of  chronic  prostatitis, 
the  factors  that  predispose  the  individual  to  the  condition  are  those 
that  predispose  to  inflammation  generally.  In  addition,  to  those  fac- 
tors peculiarly  prone  to  cause  congestion  of  the  prostate  gland  thus 
inviting  the  activity  of  bacteria,  must  be  attributed  a  predisposing 
influence  in  the  hypertrophic  changes  that  occur  later  in  life.  On  the 
other  hand,  if  later  studies  disclose  the  neoplastic  nature  of  prostatic 
hypertrophy,  the  predetermining  factors  deserving  special  consider- 
ation will  be  those  to  which  we  now  attribute  a  predisposing  influence 
to  tumor  formation  elsewhere.  At  the  present  time  we  cannot  hope  to 
reach  any  definite  conclusion  as  to  the  influences  exerted  by  occupa- 
tion, personal  habits,  previous  disease  of  the  generative  organs  and 
similar  possible  causes  of  prostatic  enlargement. 

Race. — It  does  not  appear  probable  that  race  per  se — that  is,  apart 
from  the  personal  habits  characteristic  of  any  particular  race — exerts 
special  influence  in  predisposing  to  the  disease  in  question. 

The  negro  race  has  been  held  to  be  rather  less  predisposed  to  this 
affection  than  is  the  white.  Conner  expressed  this  opinion;  Schultz 
we  believe  has  made  a  similar  statement;  but  the  opinions  of  both  sur- 
geons appear  to  have  been  based  on  general  impressions  rather  than  on 
accurate  records,  and  must  hence  be  accepted  somewhat  guardedly. 
Our  own  impression  agrees  entirely  with  theirs,  but  is  based  on  no  more 
substantial  grounds.  The  well-known  salaciousness  of  the  negro,  how- 
ever, should,  if  all  theories  are  correct,  render  him  rather  more  hable 
to  prostatic  enlargement  than  the  white  man;  since  it  is  held  that 
prostatic  overstrain  and  former  inflammations  of  the  gland  are  among 
the  most  probable  of  causes  for  its  overgrowth. 

In  natives  of  India  there  is  probably  little  doubt  that  prostatic 
enlargement  is  abnormally  frequent.  Wanless  has  given  considerable 
attention  to  this  matter,  and  his  experience  shows  that  enlargement 
of  the  prostate  with  complete  retention  of  urine  is  quite  common  in 
that  country.     He  is  of  the  opinion  that  the  chief  cause  lies  in  the 


Race  and  Age  77 

excessive  sexual  excitement,  "for  the  reason  that  sexual  intercourse  is 
begun  earlier  and  continued  later  in  life  than  ...  in  western  coun- 
tries. "  Among  other  possible  causes,  he  mentions  the  excessive  use  of 
curry  and  hot  spices,  so  common  in  India.  These  condiments  produce, 
by  their  habitual  use,  constipation  and  engorgement  of  the  portal  cir- 
culation; and  thus  a  chronic  congestion  of  the  hemorrhoidal  vessels 
arises,  which,  as  already  pointed  out,  tends  to  impede  the  circulation 
in  the  varicose  prostatic  plexus.  The  complete  urinary  retention 
which  he  observed  so  often  in  India  occurred  chiefly  at  the  time  of  the 
monsoon  rains,  when  exposure  and  chilling  were  almost  unavoidable; 
and  in  practically  every  case  of  urinary  retention  the  cause  was  pros- 
tatic obstruction.  Still  another  cause,  and  one  which  favored  the 
formation  of  phosphatic  calculus,  was  the  concentration  of  the  urine 
due  to  prolonged  work  under  the  hot  tropical  sun;  so  much  of  the  bodily 
fluids  being  thrown  off  by  the  sweat  glands  that  the  urine  excreted  was 
abnormally  concentrated. 

In  Turkey,  also,  prostatic  troubles  are  comparatively  frequent, 
chiefly  due,  according  to  Wishard,  to  excessive  sexual  activity.  In 
China  and  Japan,  however,  they  are  considered  to  be  extremely  rare; 
but  probably  not  alone  on  account  of  the  absence  of  the  same  exciting 
cause. 

Age. — Age  appears  to  exert  a  marked  influence,  although  it  is  not 
any  longer  regarded  as  a  cause  sine  qua  non.  More  and  more  it  is 
becoming  recognized  that  it  is  not  the  prostatic  enlargement  which 
develops  first  in  old  age,  but  that  it  is  the  symptoms  of  this  disease 
which  begin  to  manifest  themselves  only  in  the  decline  of  life.  Some 
fifty  years  ago  or  more,  prostatic  troubles  in  men  under  sixty  years  of 
age  were  next  to  unknown.  Sir  Henry  Thompson  stated  that  enlarge- 
ment of  the  prostate  never  occurred  under  fifty- three  years  of  age; 
but  McGill  operated  on  two  men,  aged  fifty-three  and  fifty-four  years 
respectively,  in  whom  enlargement  must  have  existed  for  some  time 
before  the  patients  were  seen  by  him.  McGill  later  reported  another 
patient  in  whom  enlargement  existed  at  thirty-five  years.  MouUin 
mentions  the  age  of  one  of  his  patients  as  forty-nine  years,  and  refers 
to  one  of  Henderson's  patients  aged  forty-eight  years,  and  to  other 
patients  of  forty-one  and  thirty-six  years;  while  Mudd  reported  cases 
occurring  in  a  young  negro  of  twenty-seven,  in  a  child  of  five  years, 
and  in  an  infant  of  thirteen  months.  But  in  spite  of  these  unique 
examples,  the  fact  remains  that  symptoms  due  to  enlargement  of  the 
prostate  under  fifty  years  of  age  are  very  seldom  observed.     The 


78  Etiology  and  Predetermining  Factors 

researches  of  Thompson,  Dittel,  and  others  have  shown  that  appre- 
ciable enlargement  exists  in  about  one-third  of  persons  over  sixty  years 
of  age,  but  that  it  produces  manifest  symptoms  in  only  one  out  of  every 
twenty.  When  the  seventieth  year  has  passed  without  enlarge- 
ment of  the  prostate,  subsequent  trouble  from  it  is  very  unusual. 
Humphrey  stated  that  only  seventeen  out  of  seventy-two  patients 
between  the  ages  of  eighty  and  ninety  years,  and  only  one  out  of 
thirty  patients  over  ninety  years,  presented  symptoms  of  prostatic 
enlargement. 

Hunter  McGuire  held  that  while  enlargement  of  the  prostate  might 
exist  in  younger  men,  yet  the  symptoms  were  not  manifested  until 
the  urinary  tract,  in  company  with  the  rest  of  the  body,  showed  the 
results  of  senile  changes.  Such  an  explanation  as  this  is  in  accord 
with  the  fact  that  natives  of  India  and  other  tropical  countries,  as  a 
rule,  show  symptoms  of  prostatic  enlargement  some  fifteen  or  twenty 
years  earlier  than  do  the  inhabitants  of  more  temperate  climes,  their 
span  of  life  being  so  much  shorter  than  ours. 

The  collection  of  many  series  of  statistics  within  recent  years  estab- 
lishes the  fact  that  prostatic  hypertrophy  is  essentially  a  disease  of 
senility;  age  being  by  far  the  most  important  predisposing  factor  in  its 
development. 

True  examples  of  the  disease  are  found  in  comparatively  young 
men,  but  these  are  rare  exceptions  to  the  general  rule  that  prostatic 
hypertrophy  is  a  disease  of  the  declining  years  of  life.  We  have  re- 
moved an  enlarged  prostate  by  the  infrapubic  route  from  a  man  aged 
29  years  and  have  operated  on  several  others  under  the  age  of  forty, 
but  as  shown  in  the  tables  given  below,  the  vast  majority  of  our  patients 
have  been  men  well  advanced  in  years. 

Prostatism  dependent  upon  lesions  involving  Albarran's  group  of 
tubules,  or  due  to  inflammatory  infiltration  around  the  vesical  neck  is 
frequently  met  with  in  young  men. 

Statistics  based  on  the  clinical  records  of  operative  cases  differ 
somewhat  from  those  dealing  with  autopsy  material;  in  the  latter  the 
percentage  of  obstructive  factors  is  likely  to  favor  the  extra-prostatic 
causes,  of  which  abnormalities  in  the  ■  Albarran's  group  of  tubules  is 
most  important. 

Undoubtedly  the  disease  process  in  the  prostate  leading  to  hyper- 
trophy begins  long  before  the  advent  of  the  first  clinical  signs  of  its 
presence  appear  but,  as  the  following  tables  show,  the  majority  of  pros- 
tatics  present  themselves  for  operation  after  the  age  of  sixty  years. 


Race   and   Age 


79 


Age  iNaDENCE  of  Patients  with  Benign  Prostatic  Hypertrophy  Tabulated  from 
THE  Records  of  the  Lankenau  Hospital  of  Philadelphia 


19. 6  per  cent. 


45 

50 

7 

50 

55 

20 

55 

60 

33 

60 

65 

71 

65 

70 

52 

70 

75 

50 

75 

80 

18 

80 

85 

8 

Total 

269 

45 . 7  per  cent. 


25.3  percent. 


Figures  approximately  the  same  as  the  foregoing  are  reported  by 
Wilson  and  McGrath  from  the  Mayo  Clinic. 


50 
60 
70 
80 
Total.. 


60 

65 

70 

194 

80 

116 

90 

12 

387 

17  percent. 

50  per  cent. 

30  per  cent. 

3  per  cent. 


Lowsley  in  a  careful  study  of  224  autopsy  specimens  has  given  the 
percentage  incidence  of  the  various  causes  of  obstruction  at  the  vesical 
outlet  together  with  the  age  incidence  of  these  abnormalities.  His 
tabulated  statistics  are  here  reproduced. 


Hypertrophy  of 
Albarran's  group 

General 
hypertrophy 

3 

U 

a.Sf 

J 

1 
•s 

d 

1'^ 

<  s 

2?  b 

CO     H 

C    to 

a  g 

Hi 

2 

V 

c 
S.  & 

Percentage  of  subtri- 
gonal  glandular  hy- 
pertrophy 

c 
< 

"0 

Age 

Large 

Medium 

Small 

Large 

SUght 

1> 

Is 

First  decade,    i- 

10  years 

Second      decade, 

10-20  years. . . 
Third  decade,  20- 

30  years 

Fourth      decade, 

30-40  years .  .  . 
Fifth  decade,  40- 

50  years 

Sixth  decade,  so- 

60  years 

Old  age,  60  years 

and  older 

0 
0 
0 
2 
4 
I 
I 

0 
0 
0 
0 
2 
2 
3 

0 
0 
2 
7 
4 
2 
3 

0 
0 

0 

0 

I 
2 
3 

0 
0 

I 
4 
6 

I 
7 

0 
0 
0 

I 
0 

I 
I 

38 
10 
40 
33 
42 
29 
32 

0 

0 

S.O 

27.3 
23.8 
17.2 

21.9 

0 
0 

2.S 
12. 1 
16.7 
10.3 
31.2 

0 

0 

0 
30 

0 
3-4 
30 

0 
0 

7.S 
42.4 
40.  S 

3  9 
S6.1 

Total  for  all 
ages 

8 

7 

18 

6 

19 

3224 

Percentage  of  Albarran's  hypertrophies,  all  ages  considered.. 

Percentage  of  general  hypertrophies,  all  ages  considered 

Percentage  of  Albarran's  hypertrophies,  after  the  20th  year. 

Percentage  of  general  hypertrophies,  after  the  20th  year 

Percentage  of  Albarran's  hypertrophies,  after  the  30th  year. 
Percentage  of  general  hypertrophies,  after  the  30th  year 


14-7 
It.  I 
18.7 
14. 1 

32.1 

175 


8o  Etiology  and  Predetermining  Factors 

Occupation. — It  is  not  probable  that  occupation  exerts  very  much 
influence  over  the  development  of  prostatic  troubles.  Some  of  the 
earlier  writers  thought  that  excessive  horseback  riding  caused  enlarge- 
ment of  the  prostate;  and  in  more  recent  times,  bicycle  or  motor  cycle- 
riding,  has  been  held  responsible  for  the  production  of  this  condition 
in  certain  patients.  Probably  of  more  real  etiological  value  in  this 
respect  than  such  direct  causes  are  factors  which  exert  their  influence 
indirectly,  such  as  a  sedentary  Hfe,  or  other  habits  which  predispose  to 
pelvic  congestion. 

Social  Habits. — Under  the  title  of  "high-living"  may  be  grouped  a 
certain  number  of  influences  which  undoubtedly  make  the  patient 
prone  to  prostatic  troubles.  The  gouty,  the  rheumatic,  the  lithemic; 
the  man  with  hepatic  and  portal  congestion,  with  a  tendency  to  hemor- 
rhoids, or  to  varicose  veins  of  the  legs,  is  a  not  infrequent  victim  of 
enlarged  prostate;  and  thus,  as  Wanless  has  pointed  out,  in  the  case  of 
the  Indian  noted  above,  dietetic  habits  or  errors  may  become  potent 
though  indirect  causes  of  enlargement  of  the  prostate  gland.  In  many 
respects  the  causes  of  this  malady  and  those  predisposing  to  the  forma- 
tion of  vesical  calculus  are  the  same,  and  the  concurrence  of  the  two 
affections  is  frequent. 

Over-indulgence  in  sexual  intercourse  has  long  been  considered  a 
possible  factor.  From  the  enlarged  and  tender  prostate  of  the  young 
masturbator,  to  the  similar  organ  of  the  old  man  who  marries  a  young 
wife — ^it  has  been  common  to  blame  the  sexual  excitement  as  the  effi- 
cient cause;  but,  as  remarked  by  J.  William  White  it  is  probably  quite 
as  logical,  if  not  more  so,  to  blame  the  enlarged  prostate  with  exciting 
unnatural  desires.  In  accord  with  this  view  was  the  recommendation 
of  Tobin,  who  regarded  persistence  of  sexual  desires  in  old  men  as  an 
indication  for  double  castration.  Lydston  teaches  that  enlargement 
of  the  prostate  is  in  great  part  due  to  its  "overstrain,"  which  he  defines 
as  hyperfunctional  activity  of  the  organ;  this  overstrain,  he  thinks, 
may  have  occurred  in  early  or  middle  life  (from  prostatitis,  urethritis, 
congestions  from  masturbation  or  ungratified  sexual  desires,  etc.),  and 
yet  may  not  show  itself  until  past  middle  life,  when  a  general  sclerotic 
tendency  arises — as  an  old  injury  to  the  knee,  for  example,  will  only 
begin  to  give  permanent  symptoms  when  gout,  rheumatism,  arthritis 
deformans,  or  some  similar  disease  make  its  appearance.  Harrison, 
arguing  along  lines  somewhat  opposed  to  the  overstrain  theory  of 
Lydston,  said:  "That  the  withdrawal  of  a  portion  of  that  function  of 
the  prostate  in  which  it  has  been  the  most  actively  engaged,  should  be 


Social    Habits  8i 

followed  by  a  continued  activity  in  which  growth  is  substituted  for 
secretion,  is  not,  I  consider,  patholo^cally  illogical."  But  Hodgson, 
on  the  other  hand,  thought  the  enlargement  might  well  be  due  to  the 
necessity  which  the  prostate  was  under  of  supplying  a  fluid  for  sexual 
intercourse  after  the  secretion  of  the  testicles  had  become  insufficient 
for  that  purpose. 

The  whole  subject  of  the  relations  of  the  testicles  to  the  prostate  is 
quite  obscure,  and  many  very  contradictory  and  apparently  irreconcil- 
able facts  are  at  hand.  The  testicles  undoubtedly  furnish  to  the 
economy  an  internal  secretion,  the  action  of  which  at  the  advent  of 
puberty  produces  the  sexual  characteristics  of  the  individual.  If  the 
testicles  are  removed  before  puberty,  the  boy  remains  of  neutral  sexual 
characteristics,  and  the  prostate  and  seminal  vesicles  fail  to  develop. 
If  the  testicles  are  removed  after  puberty,  the  sexual  characteristics 
which  were  then  acquired  do  not  disappear,  but  in  some  instances 
atrophy  of  the  prostate  and  seminal  vesicles  occurs.  Cryptorchism  in 
no  way  prevents  the  development  of  the  .sexual  characteristics,  show- 
ing that  these  depend  upon  the  internal  secretion  of  the  testicles  for 
their  manifestation,  and  not  upon  the  power  of  procreation  possessed 
by  the  individual.  From  certain  observations  it  seems  probable  that 
the  prostate  is  more  closely  connected  with  the  epididymis  and  the  vas 
deferens  than  with  the  testicle,  since  some  persons  have  been  observed 
with  two  normal  testicles,  but  with  an  undeveloped  vas  deferens  on 
one  side,  the  corresponding  half  of  the  prostate  being  rudimentary. 
Likewise  a  unilateral  development  of  the  prostate  has  been  noticed 
where  the  kidney  and  ureter  on  the  same  side  were  absent.  Remete 
was  of  the  opinion  that  only  normal  prostates  are  caused  to  atrophy  by 
castration;  and  that  the  more  hypertrophied  a  prostate  is,  the  less 
likely  is  castration  to  produce  any  beneficial  effect  upon  it.  It  is 
certainly  true  that  removal  of  one  testicle  does  not  usually  cause  atrophy 
of  the  corresponding  half  of  the  prostate,  even  when  this  latter  organ  is 
normal.  Moreover,  Moses  observed  a  case  in  which  prostatic  enlarge- 
ment developed  for  the  first  time  some  years  after  double  castration. 
MacEwen,  similarly,  advocated  the  theory  that  the  testicles  furnished 
an  internal  secretion  which  regulated  the  growth  of  the  prostate,  and 
that  enlargement  occurred  when  the  testicular  atrophy  of  age  caused 
this  influence  to  be  in  abeyance.  It  is  interesting  to  note  the  observa- 
tions of  Ciechanowski  in  this  connection.  He  showed  that  dogs  are 
the  only  domestic  animals  which  have  an  infectious  urethritis.  It 
is  well  known  that  of  all  animals  dogs  are  most  prone  to  enlargement  of 
6 


82  Etiology  and  Predetermining  Factors 

the  prostate.  Moreover,  in  other  animals  castration  invariably  causes 
prostatic  atrophy,  but  in  dogs  it  often  fails  to  produce  any  beneficial 
influence. 

If  the  influential  internal  secretion  comes  from  the  testicles,  it  is 
difficult  to  see  how  ligation  or  excision  of  a  part  of  the  spermatic  cords 
or  vasa  deferentia  could  cause  atrophy  of  the  prostate,  unless  it  were  by 
first  producing  a  change  in  the  testicles  themselves;  indeed,  it  seems 
not  impossible  that  the  atrophy  is  due  entirely  to  the  physiological 
rest  which  is  obtained  for  the  prostate  through  the  absence  of  sexual 
desire.  But,  on  the  other  hand,  it  must  be  remembered  that  castration 
does  not  always  cause  a  loss  of  sexual  desire.  Mere  subsidence  of  con- 
gestion is  a  much  more  usual  result  of  castration  than  is  actual  atrophy. 
A  further  fact  in  favor  of  physiologic  rest  being  the  cause  of  prostatic 
atrophy,  however  its  action  is  obtained,  is  the  observation  of  Hodgson 
of  a  patient,  aged  thirty-five  years,  whose  penis  had  been  amputated 
some  years  before  his  death :  in  this  case  the  autopsy  showed  the  pros- 
tate, the  seminal  vesicles,  and  the  testicles  all  much  reduced  in  size. 

All  these  considerations  really  bring  us  back  to  the  proposition  with 
which  we  started,  that  excessive  sexual  intercourse  is  probably  a  fre- 
quent predetermining  factor  in  enlargement  of  the  prostate  gland.  It 
is  not,  however,  the  only  cause,  nor  in  all  probability  the  most  important 
one.  This  affection,  as  is  well  known,  has  at  times  afflicted  the  most 
moral  and  continent  of  men. 

Previous  Diseases. — Probably  the  most  prevalent  of  all  causes  is  a 
preceding  inflammation  of  some  kind.  The  views  of  Ciechanowski 
and  others  on  this  subject  have  already  been  discussed,  and  a  mere 
reference  to  the  question  is  here  required.  Naturally  the  most  frequent 
of  these  inflammations  is  the  gonorrhoeal;  and  although  many  patients 
of  over  sixty  years  may  have  forgotten  it,  or  may  be  unwilHng  to 
acknowledge  it,  yet  a  negative  history  in  this  respect  cannot  carry  too 
much  weight.  Even  if  the  inflammation  of  the  deep  urethra  and  the 
prostate  have  not  been  of  gonorrhoeal  origin,  repeated  attacks  of  conges- 
tion and  catarrhal  exudation,  from  other  causes,  frequently  occur  in 
this  part  of  the  human  frame. 

Stricture  of  the  urethra  has  been  thought  by  some  authors  rather  to 
militate  against  prostatic  obstruction,  from  the  increased  fluid  pressure 
which  exists  behind  the  seat  of  stricture  tending  to  dilate  the  prostatic 
urethra.  Yet  a  stricture  of  some  size  is  present  in  many  cases  of 
enlarged  prostate. 

Other  diseases  may  act  as  predisposing  causes.     Among  these, 


Previous  Disease  83 

arteriosclerosis  is  prominent  in  the  nosological  tables  of  the  French 
school.  Other  affections,  such  as  cardiac  insufficiency,  hepatic  cirrhosis, 
or  other  diseases  which  cause  congestion  of  the  pelvic  organs,  should  also 
be  considered;  but  their  action  is  very  indirect,  and  probably  a  mere 
coincidence,  not  an  actual  cause. 

REFERENCES  (CHAPTER  IV) 

Albarran  et  Hall6:  Annal.  d.  mal.  d.  org.  Gen.-urin.,  1898,  xvi,  797. 

Ciechanowski:  Annales  des  Maladies  des  Organ-Urin.,  1901,  xix,  536;  Anatomical  Re- 
searches on  Prostatic  Hypertrophy.  Translated  by  Greene,  1903;  Mittheil.  a.  d. 
Grenzgeb.  d.  Med.  u.  Chir.,  1900,  vii,    183. 

Conner:  Trans.  Amer.  Surg.  Ass.,  1893,  xi,  210. 

Crandon:  Annals  of  Surgery,  1902,  xxvi,  813. 

Culver,  H.,  Jour.  Amer.  Med.  Assoc,  1916,  Ixvi,  8. 

Deaver,  McFarland  and  HermSk:  The  Breast:  Its  Diseases,  Its  Anomalies  and  Their 
Treatment.     P.  Blakiston's  Son  and  Co.,  Phila.,  Pa.,  1917. 

Dittel:  Wien.  med.  Woch.,  1876,  xxvi;  Nos.  22-25. 

Dudgeon  and  Wallace:  British  Med.  Jour.,  1904,  i,  1744. 

Freyer,  P.  J.:  Lancet,  1913,  i,  1907;  1075.  British  Med.  Jour.,  1919,  i,  121;  Surgical  Dis- 
eases of  the  Urinary  Organs,  1908. 

Greene  and  Brooks:  Jour.  Amer.  Med.  Ass.,  1902,  i,  1051. 

Guyon:  Legons  sur  les  Maladies  des  Voies  Urinaires,  Paris,  1903,  4e.  fed.,  i,  passim. 

Harrison,  Reginald:  Ashhurst's  Internat.  Encycl.  of  Surgery,  New  York,  1888,  2d  ed.,vi, 
265. 

Hitchins,  A.  P.,  and  Brown,  C.  P.:  The  Bacteriology  of  Chronic  Prostatitis.  The  Ameri- 
can Jour,  of  Public  Health,  1913,  iii,  884. 

Hodgson:  The  Prostate  Gland  and  Its  Enlargement  in  Old  Age,  London,  1856. 

Humphrey:  Old  Age  and  the  Changes  Incidental  to  it,  Cambridge,  1889,  p.  23. 

Lowsley:  Surg.,  Gyn.  and  Obstr.,  1915,  xx,  187. 

Lydston:  Interstate  Med.  Jour.,  1902,  ix,  473. 

MacEwen:  Wien.  med.  Presse,  1897,  xxxviii,  769. 

McGill:  Trans.  Clin.  Soc.  London,  1888,  xxi,  52,  Internat.  Centralbl.  f.  d.  Physiol,  u. 
Pathol,  d.  Harn-u.  Sexualorg.,  1890,  i,  249. 

McGuire,  Hunter:  Ashhurst's  Internat.  Encycl.  of  Surgery,  1895,  vii,  916. 

Moses:  Therapeutische  Monatshefte,  1895,  ii,  690;  191 7. 

Moullin:  Enlargement  of  the  Prostate,  London,  1899,  2d  ed.;  1904,  3d  ed. 

Mudd:  See  Belfield:  Amer.  Jour.  Med.  Sciences,  1890,  c,  439;  St.  Louis  Med.  and  Surg. 
Jour.,  1883,  xlv,  438. 

Remete:  Wiener  klin.  Rundschau,  1903,  xxviii,  3. 

Rosen,  R.:  The  Bacterial  Content  of  the  Prostate  and  Its  Relation  to  Prostatic  Adenoma. 
Jour.  Infect.  Diseases,  1919,  xxiv,  164. 

Rovsing:  Die  Behandlung  der  Prostatahypertrophie.    Arch.  f.  klin.  Chir.,  1902,  Ixviii,  934. 

Thompson,  Henry:  Diseases  of  the  Prostate,  London,  1868. 

Tobin:  British  Med.  Jour.,  1902,  i,  774. 

Velpeau:  Treatise  on  Diseases  of  the  Breast.  Translation  of  the  Sydenham  Soc.,Iondon, 
1856,  p.  287. 

Wade,  Henry:  Annals  of  Surgery,  1914,  lix,  321. 

Wanless:  Indian  Med.  Gazette,  1904,  xxxix,  45;  82. 

White,  J.  William:  Trans.  Amer.  Surg.  Assoc,  1893,  xi,  167. 

Wilson  and  McGrath:  Surg.,  Gyn.  and  Obstr.,  1911,  647-681. 

Wishard:  N.  Y.  Med.  Jour.,  1901;  Jour.  Cut.  and  Gen.-Urin.  Dis.,  1902,  xx,  245. 

Young,  Geraghty  and  Stevens:  Johns  Hopkins  Hospital  Reports,  1906,  xiii,  125. 


CHAPTER  V 

PATHOLOGY;  GROSS  AND  MICROSCOPIC 

It  is  necessary  to  describe  under  the  above  headings  not  only  the 
physical  characteristics  of  the  enlarged  prostate  gland  but  also  certain 
extra-prostatic  causes  of  chronic  urinary  obstruction.  Among  the 
latter  conditions  are  included  median  bar  obstructions  and  other  patho- 
logical changes  which  occur  in  the  retjjion  of  the  vesical  outlet.     Our 


■w  I 


/ 


\ 


X 


Fig.  26. — Hypertrophy  of  Lateral  and  Middle  Lobes  of  Prostate.     Great  Hyper- 
trophy OF  THE  Bladder. 
{MacCallum,  "A  Text-book  of  Pathology."      W.  B.  Saunders  and  Co.,  1916.) 

efforts  will  first  be  devoted  to  a  description  of  the  gross  characteristics 
of  the  enlarged  prostate  gland  reserving  the  extra-prostatic  conditions 
for  separate  description. 

84 


Size  and  Direction  of  Growth  gr 

Size  and  Direction  of  Growth  of  the  Enlarged  Prostate.— Any 

prostate  weighing  more  than  twenty-three  grams  may  be  considered 
abnormal.  From  this  size  they  range  up  to  three  hundred  and  seventy- 
three  grams  or  over  in  weight.     Freyer  has  removed  one  weighing  five 


Fig.     27. — View  of  an  Enlarged  Prostate  (No.  1469),  Measuring  2  X  1.5  X  i  cm. 
A  Catheter  has  been  Introduced  through  the  Urethra. 

The  patient,  D.  D.,  aged  fifty-eight  years,  was  admitted  to  (the  German,  now)  the  Lank- 
enau  Hospital,  May  4,  1903.  His  bowels  were  regular;  he  had  used  alcohol  and  tobacco 
moderately.  He  complained  of  a  burning  sensation  after  urination.  About  one  month 
before  admission  he  had  evidently  suffered  from  an  attack  of  acute  cystitis,  being  com- 
pelled to  urinate  every  ten  minutes,  and  passing  only  10  to  15  cc.  at  a  time.  His  urine  was 
highly  colored,  red,  supposed  to  be  bloody.  His  pain  was  more  marked  on  moving 
about.  Formerly  he  was  forced  to  urinate  every  twenty  minutes  during  the  night;  of 
late  he  has  not  urinated  so  often,  usually  three  or  four  times  in  a  night.  The  pain  starts 
just  above  the  symphysis  pubis  and  shoots  down  the  penis;  there  is  also  a  stinging  sensa- 
tion at  the  end  of  the  penis. 

The  operation  of  suprapubic  prostatectomy  was  performed,  and  a  vesical  calculus 
removed  at  the  same  time.  Recovery  was  prompt,  and  the  patient  was  discharged, 
entirely  relieved  of  his  urinary  symptoms,  June  3,  1903. 

The  prostate.  No.  1469,  which  is  small  and  fibrous  in  character,  is  shown  in  the  accom- 
panying figure. 


86  Pathology 

hundred  and  thirty-five  grams.  He  has  also  removed  prostates  weigh- 
ing three  hundred  and  fifteen,  and  three  hundred  and  eight  grams, 
respectively,  with  perfect  functional  result.  The  measurements  of 
this  last  gland  were  twelve  and  a  half  centimetres  antero-posteriorly, 
and  eight  and  a  half  centimetres  transversely.  The  average  weight  of 
prostates  removed  at  operation  is  probably  not  over  eighty-five  grams; 
and  the  dimensions  rarely  exceed  five  centimetres  transversely  or 
seven  and  a  half  centimetres  in  the  antero-posterior  diameter.  The 
greater  the  amount  of  fibrous  tissue  present,  the  smaller  the  organ,  other 


Fig.  28. — View  of  an  Enlarged  Prostate  (No.  1555),  Measuring  6  X  4.5  X  3  cm. 
AND  Weighing  52  Grams.  A  Catheter  has  been  Introduced  through  the 
Urethra. 

The  patient,  J.  M.  C,  aged  sixty-three  years,  was  admitted  to  the  (German,  now) 
Lankenau,  Hospital  July  18,  1903.  He  has  used  alcohol  moderately;  tobacco  to  excess. 
Six  months  before  admission  he  first  noticed  difficulty  in  starting  the  stream,  especially 
in  the  morning.  As  a  rule,  he  was  compelled  to  urinate  only  once  during  the  night,  and 
during  the  day  he  passed  urine  about  four  or  five  times.  He  stated  that  the  amount 
passed  was  scanty,  and  that  he  had  slight  pain  on  starting  the  stream.  One  week  before 
admission  he  had  his  first  attack  of  retention,  caused  by  exposure  to  cold  and  rain.  He 
was  relieved  by  catheterization,  and  has  had  subsequently  to  be  catheterized  twice  a  day. 

On  admission  the  amount  of  residual  urine  was  found  to  be  60  cc.  (2  ounces).  Rectal 
examination  revealed  a  hard  mass  at  the  neck  of  the  bladder,  about  the  size  of  a  large  hen's 

egg. 

Operation  (suprapubic  prostatectomy)  was  undertaken  a  couple  of  days  later.  Re- 
covery was  uneventful,  and  the  patient  was  discharged  August  14,  1903,  entirely  relieved 
of  his  urinary  symptoms. 

The  prostate.  No.  1555,  which  is  shown  in  the  accompanying  figure,  is  a  good  example 
of  the  moderately  firm  fibrous  type  of  enlargement.  Its  weight  was  52  grams  (if 
ounces). 


Size  and  Direction  of  Growth 


87 


things  being  equal,  and  the  greater  the  relative  weight.  The  average 
weight  of  forty  adenomatous  prostates  we  find  was  one  hundred  and 
twelve  and  a  half  grams;  and  of  ten  fibrous  prostates  the  average 
weight  it  was  sixty  grams. 

Enlargement  of  the  prostate  is   almost  invariably  due  to   the 
development   within   the   substance   of  the  gland  of  adenoma-like 


Fig.   29. — View  of  an  Enlarged  Prostate  (No.  1623),  Measuring  7X6.5X5  cm.  and 
Weighing  122  Grams.    A  Catheter  has  been  Introduced  through  the  Urethra. 

The  patient,  T.  C,  aged  seventy-seven  years,  was  admitted  to  the  (German,  now) 
Lankenau,  Hospital  September  19,  1903.  He  had  been  suffering  from  frequency  of 
urination  for  years,  the  calls  being  more  marked  at  night.  Ten  days  before  admission 
urination  became  extremely  difficult,  and  three  days  previously  it  had  become  impossible. 
For  two  days  he  had  been  catheterized  by  his  family  phjrsician,  but  on  the  third  day  it 
became  impossible  to  introduce  the  catheter. 

On  admission  the  bladder  was  found  to  be  greatly  distended,  reaching  to  the  umbilicus. 
A  prostatic  catheter  was  passed,  several  strictures  being  encountered  anteriorly;  while  in 
the  prostatic  urethra  there  was  detected  a  large  false  passage,  leading  to  the  left.  The  pros- 
tate was  greatly  hypertrophied,  the  size  of  a  small  orange.  The  urine  obtained  by 
catheterization  was  very  bloody.  After  treatment  by  intermittent  catheterization  for  two 
days,  on  September  21,  1903,  an  English  catheter  was  passed,  and  permanently  retained. 

Operation  (suprapubic  prostatectomy)  was  undertaken  September  23,  1903.  The 
patient  never  rallied,  and  died  from  shock  and  suppression  of  urine  within  a  few  hours. 

The  prostate.  No.  1623,  which  is  shown  in  the  accompanying  Plates,  weighed  122 
grams  and  is  a  good  example  of  cystic  enlargement. 


88 


Pathology 


nodules.  These  nodules  which  have  a  spongy  appearance,  though 
varying  in  density,  are  surrounded  by  a  more  or  less  complete  capsule. 
The  latter  is  composed  of  dense  stroma  with  an  admixture  of  muscle 
fibres.  Microscopically  the  nodules  are  composed  of  newly  formed 
glands  together  with  an  increased  stroma  although  the  latter  contrib- 
utes but  little  to  the  actual  size  of  the  nodule.  Enlargement  of  the 
prostate  due  to  hyperplasia  of  the  fibrous  connective  tissue  and 
muscular  elements  in  the  absence  of  glandular  increase  is  not  unknown, 
but  it  is  an  extremely  rare  type  of  prostatic  enlargement.     This  variety 


Fig.  30. — Hypertrophy  op  the  Median  Lobe.    The  Lateral  Lobes  are  not  Involved. 

(Walson.) 

must  be  differentiated  from  the  sclerotic  prostate  due  to  inflammatory 
deposits.  True  myomata  of  the  prostate  must  be  classified  among 
the  pathologic  curiosities. 

Whether  the  nodules  comprising  an  enlarged  prostate  take  origin 
from  the  glands  of  the  prostate  itself,  or,  as  is  claimed  by  some  recent 
writers,  from  peri-urethral  glands  is  beside  the  present  discussion. 
The  fact  is  that  encapsulated  adenomatous  nodules  are  found  in  the 


Size  and  Direction  of  Growth 


89 


portion  of  the  prostate  nearest  the  urethra,  and  that  the  enlargement  is 
due  to  the  presence  of  these  nodules  and  not  to  any  demonstrable 
hypertrophic  change  in  the  stroma.  The  enlarged  prostate  has  a 
relatively  increased  proportion  of  fibrous  connective  tissue;  indeed  the 
individual  specimen  may  be  classified  according  to  the  proportional 
amounts  of  fibrous  tissue  and  glandular  elements,  some  specimens 
containing  a  far  greater  amount  of  connective  tissue  than  others.  The 
larger  the  prostate,  the  less  the  relative  amount  of  fibrous  tissue 


Fig.  3i._View  of  an  Enlarged  Prostate  (No.  1533),  Measuring  6  X  6  X  4-5  cm.     A 
Catheter  has  been  Introduced  through  the  Urethra. 

present,  in  fact,  it  is  the  rule  that  in  the  absence  of  adenomatous 
nodules  the  prostate  is  likely  to  be  either  very  slightly  enlarged  or  may 
be  normal  in  size,  or  even  atrophic.  Notwithstanding  the  absence  of 
actual  enlargement,  the  sclerotic  prostate  frequently  causes  marked 
prostatism  but  for  a  different  reason  than  applies  to  the  enlarged 
adenomatous  organ.  In  the  case  of  the  latter,  the  nodules  themselves 
offer  an  obstructive  factor  to  urination  by  invading  and  distorting  the 
lumen  of  the  prostatic  urethra  and  the  bladder  orifice.     The  sclerotic 


90 


Pathology 


prostate  interferes  with  urination  by  causing  an  actual  contraction  of 
these  parts  and  is  often  complicated  by  median  bar  formation  at  the 


X 


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vesical  outlet.  Obviously  the  treatment  appropriate  to  these  widely 
differing  forms  of  the  disease  is  by  no  means  the  same.  In  the  average 
case  of  prostatism  occurring  in  a  patient  sixty  years  of  age  or  older,  the 
obstructive  factor  is  easily  enucleable;  in  the  exceptional  instance 


Size  and  Direction  of  Growth  oi 

enucleation  is  almost  impossible  for  the  reason  that  the  fibrosis  has 
proceeded  to  the  stage  where  the  entire  organ  has  become  transformed 
into  a  small,  dense,  sclerotic  mass  that  has  become  tightly  adherent  to 


Fig.  S3. — Prostate  Weighing  8i^  ounces  Removed  jfrom  Patient  Aged  79  Years. 
A.  Right  Lobe,  B.  Left  Lobe.  a'B',  outgrowths  in  the  bladder,  springing  equally  from 
both  lobes,  the  furrow  showing  the  posterior  commissure  of  the  prostate.  The  neck,  C, 
was  caused  by  the  grip  of  the  upper  margin  of  the  prostatic  sheath  or  rccto^vesical  fascia, 
and  sphincter  muscle  of  the  bladder. — {Freyer,  British  Medical  Journal,  1919,  I,  12.) 

the  surrounding  structures.  The  difiiculties  of  removing  a  prostate 
of  this  type  with  the  finger  need  no  description  for  one  who  has  attemp- 
ted it.  The  operation  can  be  performed  but  the  gland  is  literally 
torn  away  from  the  pelvic  fascia  and  other  structures  to  which  it  has 
become  firmly  adherent. 

Between  the  two  extremes  of  the  large,  soft,  freely  movable  and 


92  Pathology 

easily  enucleable  nodules  and  the  small  densely  adherent  mass  of  scar 
tissue  are  types  presenting  all  degrees  of  variation;  indeed  it  is  often- 
times a  matter  of  great  difficulty  to  classify  a  given  case  clinically  and 
as  a  corollary,  to  select  the  appropriate  form  of  treatment. 

Much  useless  controversy  has  been  indulged  in  regarding  the  origin 
of  the  so-called  middle  lobe  of  the  adenomatous  prostate.  According 
to  Keyes,  Jr.,  some  median  enlargement  is  noted  in  8i  per  cent,  of  cases 
but  this,  no  doubt,  is  meant  to  include  all  types  of  median  obstruction. 
Median  projections  into  the  floor  of  the  bladder  just  posterior  to  the 
urethra  take  origin  in  the  majority  of  instances  from  the  true  middle 
lobe  tubules.  These  tubules  lie  beneath  the  sphincter  muscle,  and 
between  the  ejaculatory  ducts  and  the  floor  of  the  prostatic  urethra. 
In  well-advanced  cases  the  origin  of  a  middle  lobe  enlargement  may  be 
differentiated,  but  only  with  great  difficulty,  from  a  pedunculated  nodule 
that  has  become  separated  through  pressure  from  one  or  the  other  of 
the  hypertrophied  lateral  lobes.  A  nodule  of  this  type,  after  invading 
the  bladder  cavity  by  way  of  the  orifice,  may  seem  to  spring  from  the 
floor  of  the  urethra.  The  study  in  early  cases  of  what  would  in  all 
probability  have  proven  to  be  generalized  hypertrophy,  if  development 
had  proceeded,  indicates  that  hyperplasia  of  the  middle  lobe  tubules  is 
a  constant  and  permanent  feature. 

The  process  shows  a  tendency  to  an  earlier  and  more  marked 
development  here  than  elsewhere,  and  in  the  majority  of  cases  the  initial 
obstructive  element  seems  to  be  a  middle  lobe  hypertrophy.  We  are 
not  prepared  however  to  accept  the  teachings  of  Tandler  and  Zucker- 
kandl  who  believe  that  so-called  generalized  hypertrophy  of  the  prostate 
is  confined  to  the  middle  lobe.  In  certain  instances  the  far  advanced 
case  of  middle  lobe  hypertrophy  presents  a  more  or  less  movable 
rounded  nodule  which  effectively  serves  to  obstruct  urination  by  a 
ball  valve  action  on  the  vesical  outlet.  More  frequently  the  nodule 
projects  upward  from  the  floor  of  the  bladder  and  serves  to  complete 
the  posterior  margin  of  a  collar -like  arrangement  of  the  intravesical 
portion  of  the  hypertrophied  lateral  lobes,  or  is  situated  within  a  ring 
formed  by  these  lobes. 

The  evidences  of  early  hypertrophy  of  the  middle  lobe  tubules  are 
to  be  looked  for  within  the  urethra  where  a  mound  will  be  found  pro- 
jecting upward  from  the  floor  of  the  canal  some  little  distance  proximal 
to  the  verumontanum.  The  walls  of  the  urethra  covering  the  projec- 
tion remain  unchanged  for  some  time.  Hyperplasia  of  the  middle  lobe 
tubules  is  easily  demonstrable  in  these  specimens. 


Disease  of  Albarran's  Tubules  93 

A  second  and  quite  frequent  source  of  obstruction  at  the  vesical 
outlet  is  disease,  either  hyperplastic  or  inflammatory,  of  Albarran's 
tubules:  this  group  of  extraprostatic  tubules  is  subcervical  in  position 
and  therefore  ideally  situated  to  embarrass  bladder  function  in  the 
event  of  their  enlargement.  Jores  was  among  the  first  to  call  attention 
to  the  fact  that  many  of  the  adenomata  situated  in  the  region  of  the 
bladder  orifice  have  their  beginning  in  accessory  prostatic  glands. 


Fig.  34. — View  of  the  Cut  Surface  of  an  Enlarged  Prostate  (No.  1542), 
Measuring  7X6X6  cm.  and  Weighing  120  Grams.  A  Catheter  has  been  Intro- 
duced THROUGH  the  UrETHRA. 

The  result  of  hypertrophic  changes  in  Albarran's  tubules  is  some- 
times seen  in  the  production  of  a  broad  median  bar  but  more  often  of  a 
rounded  nodule  which  is  separated  from  the  lateral  lobes  of  the  prostatic 
gland  by  deep  clefts,  one  on  either  side.  The  lobule  itself  is  grossly 
tri-lobular,  the  clefts  separating  the  individual  lobules  being  caused  by 
the  pressure  exerted  by  Bell's  muscle,  bundles  of  which  pass  over  it 
from  the  trigonum  above  to  the  urethral  floor  below.  These  clefts 
lend  themselves  beautifully  to  cysto-urethroscopic  demonstration  so 
that  this  type  of  median  line  obstruction  is  usually  diagnosed  with  ease. 

In  addition  to  median  obstructions  of  glandular  origin,  certain 
bars  composed  of  fibrous  connective  tissue  occur  in  the  region  of  the 


94  Pathology 

posterior  lip  of  the  vesical  orifice.  Randall  divides  these  sclerotic 
bars  into  two  groups :  One,  the  edge  of  which  is  narrow  and  extends 
from  side  to  side  forming  an  abrupt  angle  with  the  sphincteric  margin. 
The  trigonum  vesicae  is  foreshortened  and  the  verumontanum  is 
likely  to  be  found  lying  just  beneath  the  projecting'edge  of  the  bar. 

The  second  type  of  bar  is  situated  higher,  so.  that  the  trigonum  is 
affected  more  than  the  urethral  walls.     The  verumontanum  is  not 


Fig.  35. — View  of  the  Upper  Surface  of  an  Enlarged  Prostate  (No.  1542), 
Measuring  7X6X6  cm.  and  Weighing  120  Grams.  A  Catheter  has  been  Intro- 
duced through  the  Urethra. 

displaced  and  the  most  apparent  effect  is  a  transverse  folding  of  the 
trigonal  mucosa.  This  variety  of  bar  is  less  likely  to  cause  serious 
urinary  obstruction  than  its  prototype  described  above;  histologically 
they  are  exactly  the  same,  both  consisting  of  sclerotic  tissue.  The 
relative  frequency  of  these  varieties  of  median  bar  is  given  in  the  chap- 
ter on  diagnosis. 

An  infrequent  though  potent  cause  of  prostatism  is  wide-spread 


Size  and  Direction  of  Growth 


95 


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96 


Pathology 


sclerosis  in  the  region  of  the  vesical  outlet  resulting  from  prostatitis 
and  peri-pros tatitis.  The  obstructive  factor  here  is  not  limited  to 
any  segment  of  the  ring-like  outlet  of  the  bladder  but  is  distributed  in 
an  annular  manner  to  surround  not  only  the  immediate  region  of  the 
vesical  orifice  but  also  the  prostatic  urethra.  Cases  of  this  kind  are 
sometimes  met  with  in  comparatively  young  men. 


Fig.    37. — Enlarged  Prostate  (No.  1502),  Measuring  6X6X5  cm.  and  Weighing 

TOO   Grams. 

The  patient,  H.  M.  Y.,  aged  sixty-six  years,  was  admitted  to  the  German  nowLankenau 
Hospital  June  8,  1903.  The  patient's  father  had  died  of  prostatic  disease.  The  patient 
had  always  been  a  moderate  user  of  alcohol.  For  the  past  fifteen  years  he  had  suffered 
from  frequency  of  urination,  which  was  most  marked  at  night.  Two  years  before  admis- 
sion he  had  developed  an  acute  attack  of  cystitis.  In  July,  1902,  he  had  been  operated  upon 
for  vesical  calculus,  since  which  time  he  had  had  a  suprapubic  fistula.  He  had  not  passed 
urine  through  the  urethra  for  six  months. 

Rectal  examination  on  admission  showed  a  \ery  hard  prostate,  about  the  size  of  a 
lemon. 

Suprapubic  prostatectomy  was  done  June  15,  1903;  a  stone  the  size  of  a  lima  bean  was 
extracted  from  the  bladder,  and  the  prostate  removed  entire  along  with  the  prostatic 
urethra.  Recovery  was  rather  tedious,  but  the  patient  was  discharged  August  i,  1903, 
in  good  health,  and  with  no  urinary  trouble. 

The  prostate.  No.  1502,  which  is  shown  in  the  accompanying  figure,  was  the  seat  of 
considerable  catarrhal  and  interstitial  inflammation,  as  seen  by  the  microscopical  section, 
(Fig.  34).     Its  weight  was  100  grams. 


Size  and  Direction  of  Growth 


97 


F"iG.    38. — View  of  an  Enlarged  Prostate  (No.  2138)  Weighing  162  Grams.    Very 
Marked  Enlargement  of  the  Right  Lobe. 

The  patient,  W.  T.  D.,  aged  seventy-three  years,  lawyer  by  occupation,  was  admitted 
to  (the  German,  now)  the  Lankenau  Hospital  December  3,  1904.  He  had  always  used 
alcohol  and  tobacco  in  moderation.  He  had  had  the  ordinary  diseases  of  childhood,  and 
had  had  enteric  fever  twice,  in  1862  and  1863.  Since  that  time  he  has  always  enjoyed 
good  health. 

For  a  little  more  than  three  years  he  has  had  slightly  more  frequent  desire  to  urinate, 
with  occasional  imperative  urination.  Three  years  ago,  after  slight  alcoholism,  there 
developed  acute  retention  of  urine,  which  was  relieved  by  the  catheter.  For  a  week  subse- 
quently a  catheter  had  to  be  passed  twice  daily,  and  since  this  time  the  patient  has  had  to 
be  catheterized  on  the  average  of  once  in  a  week  or  ten  days,  sometimes  only  every  two 
weeks;  never  with  any  degree  of  regularity.  The  chief  indication  for  catheterization  was 
pain;  a  considerable  amount  of  urine  could  usually  be  drawn,  and  the  patient  would  urinate 
generally  about  five  times  during  the  night  following  these  catheterizations,  though  there 
would  be  times  when  he  would  not  get  up  at  all. 

On  admission  there  was  found  to  be  residual  urine  amounting  to  60  cc. 
•  Suprapubic  prostatectomy  was  done  December  8,  1904.  On  opening  the  bladder  it 
was  found  that  the  prostate  was  markedly  enlarged,  especially  upon  the  right  side,  which 
equaled  a  lemon  in  size.  On  attempting  to  enucleate  the  whole  gland  the  tip  of  the  much 
enlarged  right  lobe  broke  oflf  from  the  body  of  the  enlarged  organ,  and  lay  free  in  the  blad- 
der. It  was  removed,  and  the  remaining  portions  of  the  prostate  were  then  enucleated  m 
one  piece.  Uninterrupted  recovery  followed,  and  the  patient  is  completely  relieved  of  his 
urinary  symptoms. 

The  prostate,  No.  2138,  which  is  shown  in  the  accompanying  figures,  weighed  162  grams. 
7 


98 


Pathology 


Fig.    39.— View  of  the  Same  Prostate  (No.  2138)  shoWxV  in  Fig.  38. 
(a)   (b)  the  right  lobe,  (6)  the  intravesical  portion,      (c)  The  left  lobe. 


Size  and  Direction  of  Growth  po 

In  rare  instances  the  anterior  group  of  prostatic  tubules  are  con- 
cerned in  the  origin  of  nodules,  which  may,  or  may  not  cause  obstruc- 
tion to  urination  of  sufficient  degree  to  give  rise  to  clinical  symptoms. 


F"iG.   40. — View  of  the  Upper  Surface  of  an  Enlarged  Prostate  (No.  1826)  Weigh- 
ing 56  Grams.    A  Catheter  has  been  Introduced  through  the  Urethra. 

The  patient,  A.  S.,  aged  sixty-eight  years,  was  admitted  to  (the  German,  now)  the  Lank- 
enau  Hospital  March  25,  1904.  He  had  always  enjoyed  good  health,  and  had  lived  a 
very  active  life.  For  fourteen  months  previous  to  his  admission  he  had  had  frequency 
of  urination,  and  at  times  had  been  forced  to  use  a  catheter  every  fifteen  minutes.  For 
the  last  three  months  he  had  been  confined  to  bed  with  a  catheter  constantly  in  the  bladder. 
He  likewise  suffered  from  diabetes.  His  general  condition,  however,  improved  so  much 
after  the  institution  of  continuous  drainage,  that  an  operation  was  deemed  justifiable. 

Suprapubic  prostatectomy  was  accordingly  performed  on  March  26,  1904.  The  opera- 
tion proved  to  be  perfectly  successful.  Urine  was  voluntarily  passed  through  the  urethra 
first  on  April  6,  and  the  patient  was  soon  afterwards  discharged  with  the  suprapubic  wound 
firmly  healed,  and  with  his  urinary  functions  in  normal  condition. 

The  prostate,  No.  1826,  is  shown  in  the  accompanying  figure.  It  weighed  56  grams 
and  is  a  good  example  of  irregular  enlargement,  the  projection  of  the  so-called  middle  lobe 
making  the  under  surface  of  the  gland  nearly  clover-leaf  in  shape. 


100  Pathology 

Physical  Characters. — When  we  come  to  a  consideration  of  the 
physical  characters  of  the  enlarged  prostate  other  than  its  size  and 
weight,  we  find  the  most  important  one  from  a  therapeutic  point  of 
view  is  its  density.     This  varies  from  that  of  cartilaginous  hardness 


Fig.    41. — View  of  the  Under  Surface  of  an  Enlarged  Prostate  (No.  1826)  Weigh- 
ing 56  Grams.    A  Catheter  has  been  Introduced  through  the  Urethra. 

such  that  the  knife  creaks  as  it  cleaves  the  tissue,  to  a  glandular  softness 
which  may  perhaps  best  be  compared  to  a  wet  sponge  of  close  texture. 
The  former  characteristic,  hardness,  is  found  exclusively  in  prostates 
which  contain  much  fibrous  tissue,  and  which  we  have  placed  in  the 
second  class;  while  the  softer  the  organ,  the  more  surely  may  it  be 
considered  to  belong  to  the  adenomatous  group  of  cases.  Between 
these  two  extremes  all  grades  of  density  exist;  but  few  indeed  are  the 
cases  where  it  is  impossible  to  place  the  gland  readily  in  one  or  the 
other  category. 

The  rate  of  growth  is  variable  both  of  the  gland  as  a  whole,  and  of 
its  individual  parts.  The  soft  glandular  prostates  grow  with.greatest 
rapidity,  and  may  furnish  evidence  of  increase  in  size  to  the  palpating 


Physical   Characters 


lOI 


finger  within  a  period  of  a  few  months.  Extremely  rapid  growth  occurs 
only  in  malignant  neoplasms.  The  fibrous  prostate  grows  slowly, 
and,  as  already  remarked,  rarely  equals  the  glandular  in  size.  Some 
authors  have  even  contended  for  a  progressive  decrease  in  size  occur- 
ring in  this  form,  constituting  true  prostatic  atrophy;  but  their  views 
have  not  met  with  unreserved  acceptance.  Undoubtedly  there  is  an 
actual  decrease  in  the  size  of  the  prostate  in  certain  long-standing  cases 
of  prostatitis  and  peri-prostatitis.     In  advanced  cases  it  may  be  found 


Fig.  42. — Median  Sagittal  Section  of  the  Bladder  and  Prostate. 
Immediately  behind  the  internal  meatus,  and  under  the  mucosa  there  is  a  small  isolated 
adenoma.     The  prostate  is  otherwise  normal.     (Ramon  Guiteras  {after  Wallace),  A  Text-book 
of  Urology,  D.  Appleton  and  Co.) 

that  the  gland  tissue  has  almost  completely  disappeared  and  all  that 
remains  is  a  small  mass  of  dense  scar  tissue.  Symptoms  of  prostatism 
may  occur,  not  as  a  result  of  the  prostatic  atrophy,  but  because  the  fib- 
rous tissue  has  infiltrated  the  tissues  surrounding  the  vesical  orifice  and 
the  prostatic  urethra,  transforming  the  latter  into  a  rigid,  unyielding 
tube.  This  together  with  the  lost  suppleness  of  the  sphincter  mechan- 
ism of  the  bladder  outlet  imposes  a  heavy  burden  on  the  bladder  walls, 
the  effect  of  which  brings,  sooner  or  later,  the  picture  of  prostatism. 
The  cause  of  the  prostatic  atrophy  is  the  cause  of  the  obstruction  to 
urination;  the  atrophy  per  se  is  not,  we  believe,  the  important  factor  in 
causing  urinary  obstruction.  In  the  fibrous  variety,  moreover,  it  is 
unusual  to  find  pedunculated  or  sessile  growths  projecting  from  the 
surface  of  the  prostate,  these  so-called  prostatic  tumors  occurring 
almost  without  exception  where  the  organ  has  undergone  a  glandular 
overgrowth. 


102 


Pathology 


These  "prostatic  tumors"  are  quite  characteristic.  In  the  prostate 
have  been  found  at  times  true  tumors,  myomata,  adenomata,  and  other 
growths;  but  what  is  understood  by  a  prostatic  tumor  is  a  localized 
overgrowth  of  glandular  acini,  without  increase  in  the  number  of  the 
corresponding  ducts.     This  acinous  overgrowth   compresses   the   sur- 


FiG.  43. — A  Section  from  Prostate  inu.  1502  (see  Fig.  34)  showing  Consider- 
able Hyperplasia  and  Some  Dilatation  of  the  Glandular  Structures. 
For  the  most  part  the  lining  epithelial  cells  are  disposed  in  a  single  layer,  but  here 
and  there  are  two  or  more  layers,  which,  together  with  the  mucoid  infiltration  of  the 
cells  and  the  periacinar  round-cell  infiltration,  indicate  catarrhal  and  other  inflammatory 
alterations  (X250). 

rounding  stroma  into  a  capsular  envelop,  which  it  has  been  customary 
to  regard  as  a  myomatous  growth,  the  prostatic  tumors  being  denomi- 
nated adenomyomata.  Later  investigations,  however,  have  shown  that 
this  capsule  is  in  reality  composed  of  new  connective- tissue  elements, 
or  fibroblasts,  while  the  muscle  tissue  probably  does  not  increase  in 
quantity.  In  time  the  stroma  surrounding  these  locaHzed  glandular 
outgrowths  itself  begins  to  grow,  and  may  eventually,  according  to 


Physical  Characters  103 

Moullin,  compress  the  pre-existent  acini,  so  that  the  prostatic  tumor 
formerly  almost  wholly  glandular  in  character  becomes  eventually 
fibrous  and  solid.  Moullin  claims  that  increase  in  size,  though  less 
rapid,  still  continues  during  this  which  he  calls  the  second  stage  of  the 
pathological  process.  Whether  or  not  we  accept  this  view,  that  the 
fibrous  is  a  subsequent  stage  of  the  glandular  change,  it  is  certain  that 
the  prostatic  tumors,  no  matter  what  their  state,  are  under  considerable 
pressure  from  the  surrounding  stroma,  and  that  they  tend  to  grow  in 
the  direction  of  least  resistance.  This  latter  fact  frequently  causes 
them  to  project  beneath  the  mucous  membrane  of  the  bladder,  posterior 
to  the  urethral  orifice.  When  seated  within  the  substance  of  the  gland, 
they  are  prone  to  start  out  of  it  on  section,  and  may  readily  be  enucleated 
with  the  finger,  the  few  ducts  from  which  the  numerous  new  acini  spring, 
unless  they  are  included  in  the  section,  serving  as  their  pedicle  of  attach- 
ment to  the  rest  of  the  organ. 

In  some  cases  no  such  prostatic  tumors  are  found,  the  gland 
presenting  a  nearly  uniform,  general  enlargement,  either  glandular 
or  fibrous  in  character;  or  a  general  glandular  enlargement  may 
exist  in  some  areas,  and  a  general  fibrous  enlargement  in  others. 
When  this  is  the  case,  no  nodulation  of  the  surface  occurs. 

When  a  large  part  of  the  prostate  becomes  intravesical,  it  is 
usual  to  observe  a  constriction  between  this  and  the  extravesical 
portion.  This  constriction  is  produced  by  the  edges  of  the  prostatic 
sheath,  which  as  Mr.  Freyer  says,  has  been  shouldered  aside  by  the 
prostate  in  its  efforts  to  expand  beneath  the  mucous  membrane  of  the 
bladder. 

The  internal  vesical  sphincter  muscle  also  constitutes  a  line  of 
separation  between  the  intravesical  and  extravesical  portions  of  the 
enlarged  prostate.  In  a  certain  proportion  of  cases  it  leaves  its  im- 
print in  the  form  of  a  groove  on  the  enucleated  mass. 

During  the  last  fifteen  years,  there  seems  to  have  been  no  par- 
ticularly new  ideas  expressed  on  this  subject.  The  consensus  of  opinion 
has  shifted  from  time  to  time  but  there  still  remain  two  points  which 
need  emphasis: — first,  the  truly  adenomatous  origin  of  the  glandular 
form  does  not  seem  to  have  been  disproved,  and  second,  great  impor- 
tance must  be  attached  to  chronic  inflammation  in  the  production  of 
the  fibrous  form  of  prostatic  enlargement. 


104  Pathology 

REFERENCES  (CHAPTER  V) 

Buerger,  Leo:  Pathology  and  Operative  Treatment  of  Contracture  of  the  Neck  of  Baldder 

J.  A.  M.  A.,  1919,  Ixxiii,  1677. 
Chetwood,  C.  H. :  Different  Types  of  Fibrosis  Obstruction  of  the  Bladder  Outlet  and  Their 

Treatment.     Surg.,  Gyn.  and  Obstr.,  1915,  xx,  205. 
Cunningham,  J.  H.,  Jr.:  Cysts  of  Prostate.     Surg.,  Gyn.  and  Obst.,  1915,  xxi,  609. 
Freyer:  Lancet,  1904,  ii,  197;  British  Med.  Jour.,  1919,  i,  121;  Arch.  Internat.  de  Chir., 

19 14,  vi,  88. 
Gardner,  J.  A.:  "Diverticulum  of  the  Bladder."     Jour,  of  Urology,  191 7,  i,  439, 
Glaesel:    Ztschr.  f.  Urol.  Chir.,  1914,  ii,  353. 

Hall,  I.  S.:  Cystic  Degeneration  of  the  Prostate.     Urol,  and  Cutan.  Rev.,  1916,  xx,  664. 
Hinman,  F.:  Vesical  Diverticulum.     Surg.,  Gyn.  &  Obst.  1919,  xxix,  150. 
Jores:  Ueber  die  Hypertrophic  des  sogenannten  Mittellappens  der  Prostata.    Arch.  f. 

path.  Anat.  u.  Physiol,  u.  f.  klin.  Med.,  Berlin,  1894,  cxxxv,  224. 
Judd,  E.  S.:  Surg.,  Gyn.  and  Obst.,  19x5,  xx,  274.     Surgical  Pathology  of  Prostate  Gland. 

Journal -Lancet,  1915,  xxxv,  380. 
Keyes:  Urology,  New  York,  1917. 
Lissauer:  Anatomic  u.  Klin,  der  Prostatahypertrophie.    Centralbl.  f.  d.  Grenzgeb.  d.  Med. 

u.  Chir.,  1913,  xvii,  i. 
Lowsley:  The  Human  Prostate  Gland  in  Youth.     Med.  Rcc,  1915,  Ixxxviii,  383;  Jour. 

Am.  Med.  Assn.,  1913,  Surg.,  Gyn.  and  Obst.,  1915,  xx,  i. 
Maehr:  Lancet,  1908,  i,  1054. 
McGrath,  B.  F.:  "  Cancer  of  the  Prostate."     Trans.  Section  on  Pathology  and  Physiology, 

Sixty-fifth  Annual  Session  Amer.  Med.  Assoc,  June,  1914. 
Merrett,  E.  P.:  True  Prostatic  Calculi.     Jour.  Amer.  Med.  Assoc.,  1919,  Ixxiii,  1867. 
MouUin:  Enlargement  of  the  Prostate,  London,  1899,  2d  ed.;  1904,  3  ed. 
Pedersen:    N.  Y.  Med.  Jour.,  1913,  xcvii,  487. 

Pilcher:  Prostatic  Obstructions.     Cabot's  Modern  Urology,  Phila.  and  New  York,  191 8. 
Randall:  The  Jour,  of  Urology,  1917,  i,  383;  Annals  of  Surgery,  1917,  Ixv,  471;  524. 
Simons,  I.:  A  Case  of  Urinary  Obstruction  Due  to  Enlargement  of  the  Anterior  Lobe. 

The  Jour,  of  Urology,  1919,  iii,  43. 
Tandlcr  and  Zuckerkandl:  Folia  Urolog.,  1911,  v,  587. 
Townsend,  W.  W.:     Surg.,  Gyn.  and  Obst.,  1916,  xxiii,  685. 
Wade:  Prostatism.     The  Surgical  Anatomy  and  Pathology  of  the  Operative  Treatment. 

Ann.  Surg.,  1914,  lix,  321. 
Wilson  and  McGrath:  Surgical  Pathology  of    the    Prostate.     Surg.,    Gyn.    and    Obst., 

191 1,  xiii,  647-681. 
Young,  H.  H.:  Annals  of  Surgery,  1909,  xlix,  1232;  Jour.  Amer,  Med.  Ass.,   1906,  xlvi, 

699;  Trans.  Seventeenth  Internat.  Cong,  of  Med.,  London,  1913. 


CHAPTER  VI 

CLINICAL  PATHOLOGY:  EFFECTS  ON  URETHRA,  BLADDER, 
KIDNEYS,  URINE,  AND  RECTUM 

As  the  prostate  gland  enlarges,  whether  from  tumor  formation  or 
as  the  result  of  a  general  hyperplastic  process,  various  changes  are 
produced  in  the  urethra,  the  bladder,  and  the  rectum;  and  less  directly 
in  the  urine,  the  kidneys,  and  the  general  health. 

Effects  on  Urethra. — The  length  of  the  urethra  is  almost  always 
increased.  Its  normal  length  averages  twenty  centimetres,  according  to 
the  extensive  statistics  compiled  in  1898  by  Keyes;  but  it  varies  from 
fifteen  to  twenty-five  centimetres  in  health,  and  thus  a  length  of  over 
twenty  centimetres  may  be  no  longer  than  normal  for  any  individual 
patient;  while,  on  the  other  hand,  the  urethra  may  be  abnormally  long 
by  five  centimetres  when  its  length  merely  reaches  the  average.  In 
drawing  conclusions  from  such  measurements  the  patient's  height,  his 
age,  and  the  length  of  his  penis,  should  all  be  borne  in  mind.  The 
urethra  is  generally  considered  to  increase  slightly  in  length  with  ad- 
vancing years,  apart  from  any  pathological  change;  and,  other  things 
being  equal,  the  taller  the  patient,  and  the  longer  his  penis,  the  greater 
may  be  expected  to  be  the  length  of  his  urethra.  The  length  of  the 
penis,  however,  and  consequently  that  of  the  urethra,  varies  so  much 
in  the  same  individual,  according  to  the  local  temperature  and  nervous 
emotions  on  being  examined,  that  this  increase,  unless  marked,  and 
accompanied  by  other  symptoms,  cannot  be  regarded  as  of  very  great 
importance. 

When  the  subject  of  the  physiology  of  urination  was  under  dis- 
cussion, we  called  attention  to  the  now  discarded  theory  of  Finger. 
This  theory  held  that  the  deep  urethra  becomes,  physiologically,  a 
part  of  the  bladder  cavity  when  the  latter  is  distended  with  urine.  It 
was  then  believed  that  as  the  bladder  distends  and  the  desire  to  urinate 
becomes  increasingly  insistent,  the  internal  vesical  sphincter  muscle 
relaxes  allowing  the  urine  to  flow  into  the  deep  urethra,  whence  its 
escape  is  prevented  by  the  external  sphincter  and  the  compressor 
urethrae  muscles.  This  theory  was  supported  by  the  alleged  demon- 
stration of  a  shortening  of  the  distance  between  the  urethral  meatus 


io6 


Clinical  Pathology 


and  the  urinary  reservoir  during  distended  states  of  the  bladder.  The 
difference  between  the  length  of  catheter  necessary  to  drain  the  urine 
from  a  comparatively  empty  bladder  and  a  fully  distended  one  was 
said  to  correspond  to  the  normal  length  of  the  prostatic  urethra. 


Fig.    44. — Elevation  of  Vesical  Orifice  of  the  Urethra  and  Formation  of  a  Retro- 

PROSTATic  Pouch. 
Note  the  increased  curve  and  length  of  the  subpubic  urethra. 

We  have  failed  to  confirm  this  observation  in  a  study  ol  fifty  normal 
cases,  and  could  demonstrate  only  very  slight  differences  in  the  urethral 
length.  In  a  certain  small  percentage  of  prostatics  the  prostatic 
urethra  does  undoubtedly  become  a  part  of  the  bladder  cavity  but  for 
pathologic    rather    than   physiologic    reasons.     In    case    an    adeno- 


Effects  on  Urethra 


107 


matous  nodule  enters  the  bladder  cavity  in  such  manner  as  to  render 
ineffectual  the  sphincteric  action  of  the  muscle,  the  urine  will  find  free 
access  to  the  deep  urethra  where  it  may  be  retained  by  the  external 


Fig.    45. — Lateral  Deviation  of  the  Urethra  Towards  the  Patient's  Right,  Due 
TO  Overgrowth  of  the  Left  Lobe  of  the  Prostate. — {After  Anger.) 


group  of  sphincter  muscles,  or,  as  more  often  happens,  the  latter  muscle 
will  eventually  fail  and  incontinence  results;  not  infrequently  there 
results  an  incontinence  of  retention.     In  these  cases  the   prostatic 


io8  Clinical  Pathology 

urethra  has,  to  all  intents  and  purposes,  become  a  part  of  the  bladder 
cavity,  but  the  circumstance  is  a  rare  one. 

The  theory  of  Finger  was  finally  and  completely  disproved  when 
with  cystographic  studies  it  was  possible  to  prove  the  entire  absence 


Fig.     46. — Formation  of  a  Y-shaped  Channel  due  to  the  Presence  of  a  Pedun- 
culated "Median  Lobe." 
Several  orifices  of  vesical  pouches  are  also  seen.     A  small  concretion  is  attached  to  the 
"middle  lobe." — {After  Cruveilhier.) 

of  a  "neck"  to  the  bladder.  In  the  majority  of  instances  the  urethra 
is  elongated  in  cases  of  adenomatous  enlargement  of  the  prostate; 
in  the  fibroid  cases  on  the  contrary,  and  especially  in  the  presence  of 
fibrous  bars  at  the  vesical  orifice,  the  length  of  the  urethra  may  be 


Effects  on  Urethra 


109 


actually  shortened  through  a  diminution  in  the  length  of  the  prostatic 
urethra.  The  reason  for  this  becomes  at  once  evident  when  we  ex- 
amine the  floor  of  the  urethra  in  a  case  of  this  kind;  the  verumon- 
tanum,  which  normally  occupies  a  mid -point  on  the  floor  of  the  prostatic 
portion  of  the  canal,  will  be  found  lying  just  outside  the  vesical  orifice 
and  beneath  the  cleft-like  edge  of  the  bar. 

In  some  of  the  adenomatous  cases  the  length  of  the  urethra  may  be 
increased  up  to  thirty-five  to  forty  centimetres;  so  that  where  urinary 


Fig.    47.— Overgrowth    of    Suburethral    Portion    of    Prostate,    Changing    the 
Subpubic  Curve    of    the    Urethra. — (After   Anger.) 

retention  is  evident  the  surgeon  must  not  be  discouraged  on  failing  to 
reach  the  bladder  with  the  ordinary  length  of  catheter. 

This  increase  of  length  occurs  chiefly  in  the  prostatic  portion, 
which  may  measure  as  much  as  ten  centimetres.  The  bulbous  urethra 
is  also  lengthened. 

The  means  by  which  this  increase  in  length  is  brought  to  pass 
may  be  explained  by  the  fixation  of  the  prostate  gland  at  its  apex, 
and  the  necessity  which  therefore  exists  for  any  enlargement  to 
take  place  in  a  posterior  direction.  As  will  be  remembered,  in  speak- 
ing of  the  relational  anatomy  of  the  prostate,  attention  was  called  to 


no  Clinical  Pathology 

the  greater  firmness  of  its  attachment  to  the  rectum,  as  compared 
with  its  superior  relations;  hence  its  greater  enlargement  is  usually- 
found  extending  into  the  floor  of  the  bladder,  this  being  a  more  com- 
pressible viscus  than  the  rectum,  which  is  so  often  filled  with  solid 
fecal  matter,  while  the  fluid  contents  of  the  bladder  off^er  little  resis- 
tance to  prostatic  encroachment.  The  enlargement  upward  of  the 
prostate  explains  how  in  the  enlarged  organ  the  prostatic  utricle  comes 
to  occupy  the  lower  part  of  the  prostatic  urethra  instead  of  its  centre. 

The  fact  that  the  neck  of  the  bladder  is  thus  encroached  upon  brings 
about  a  second  change  in  the  urethra,  and  this  is  in  its  direction.  The 
vesical  orifice  of  the  urethra  is  thus  raised  from  its  normal  situation, 
even  where  no  isolated  median  enlargement  exists;  and  the  vesical 
half  of  the  prostatic  urethra  may  in  extreme  cases  assume  a  right  angle 
with  its  outer  portion,  so  that  the  curve  of  the  ordinary  metal  or  English 
catheter  will  not  fit  the  prostatic  urethra,  its  point  impinging  upon  the 
posterior  wall.  Besides  a  change  in  direction  in  the  sagittal  plane 
thus  produced,  there  may  be  a  lateral  deviation  of  the  urethra,  due  to 
unequal  enlargement  of  the  two  lateral  lobes,  the  channel  being  deflected 
towards  the  less  enlarged  lobe.  Hence  in  passing  a  metal  catheter  in 
cases  of  obstruction  from  an  enlarged  prostate,  if  the  beak  of  the  instru- 
ment cannot  be  made  to  ride  over  the  obstruction  by  depressing  its 
handle,  the  surgeon  should  turn  it  first  to  one  side  and  then  to  the  other. 
If  a  pedunculated  enlargement  exists  just  back  of  the  vesical  orifice, 
a  Y-shaped  channel  may  be  present,  and  the  catheter  will  pass  to 
either  side  of  the  median  Une. 

By  the  same  process  by  which  the  vesical  orifice  of  the  urethra  is 
raised,  the  posterior  or  inferior  wall  of  the  prostatic  urethra  is  much 
lengthened;  and  if  no  corresponding  growth  occurs  in  that  portion  of 
the  prostate  anterior  to  the  urethra,  and  the  anterior  wall  of  the  pros- 
tatic urethra  remains  unchanged,  the  diameter  and  consequently 
the  capacity  of  the  prostatic  urethra  may  be  much  increased,  so  that  it 
may  hold  thirty  to  sixty  cc.  of  urine.  Such  extreme  enlargement  is, 
of  course,  rare;  indeed,  it  more  often  happens  that  this  portion  of  the 
canal  is  more  or  less  compressed  by  the  centripetal  enlargement  of  the 
lateral  lobes,  so  that  on  transverse  section  it  appears  as  a  vertical  chink, 
instead  of  the  normal  crescentic  outline.  If  this  lateral  compression 
is  marked,  and  it  is  more  apt  to  be  so  in  cases  of  fibrous  overgrowth  than 
in  adenomatous  enlargement,  total  retention  of  urine  may  ensue,  even 
though  the  vesical  orifice  of  the  urethra  is  not  displaced,  and  the 
catheter  enters  with  its  usual  facility;  for  while  a  catheter  may  easily 


Effects  on  Urethra 


III 


overcome  very  considerable  lateral  compression,  the  bladder  will  be 
unable  to  effect  a  like  dilatation  of  the  canal  by  hydrostatic  pressure 
applied  only  to  its  vesical  orifice.  Instead  of  retention  of  urine  being 
produced  by  the  deformities  of  the  urethra  caused  by  enlargement  of 
the  prostate,  true  incontinence  of  urine — not  merely  retention  with 
overflow — has  occasionally  been  noted  where  the  eccentric  growth  of 
the  prostate  keeps  the  urethral  orifice  constantly  patulous. 


Fig.  48. — Hypertrophy  of  Lateral  and  Midlobes  of  Prostate,  showing  Antero- 
posterior Widening  of  the  Urethra. 
{MacCallum,  "A  Text-book  of  Pathology.")— W.  B.  Saunders  and  Co.,  1916. 

If  the  parts  below  the  urethra  enlarge  with  greater  rapidity  towards 
its  floor  than  towards  the  vesical  trigone,  the  normal  curve  of  the  sub- 
pubic urethra  may  be  obliterated,  the  canal  here  becoming  straight; 
or  its  convexity  may  even  be  directed  forward,  towards  the  pubic 
symphysis.  In  such  cases  the  catheter  must  be  reversed  before  it 
will  enter  the  bladder. 

Vignard  has  shown  that  among  twenty-eight  specimens  which  he 
examined,  in  sixteen  obstruction  to  urine  existed  throughout  the  whole 
prostatic  urethra;  in  nine  cases  the  obstruction  was  chiefly  at  the  vesical 
orifice,  but  also  to  some  extent  in  the  urethra;  while  in  only  three  out 
of  the  whole  twenty-eight  cases  did  it  exist  at  the  vesical  orifice  alone. 


112 


Clinical  Pathology 


Besides  the  changes  in  length,  direction,  and  size,  to  which  the 
prostatic  urethra  is  thus  subject,  it  may  be  curiously  distorted  by 
submucous  adenomata  springing  into  its  canal  from  any  direction, 
most  frequently  from  beneath  its  floor.  Failure  to  remove  such  masses, 
palpable  neither  from  within  the  bladder  nor  from  the  perineum,  is 
the  probable  explanation  of  persistence  of  symptoms  after  many  a 
prostatectomy. 


Fig.  49. — Collar-like  or  "Cervix  Uteri"  Enlargement  of  Prostate,  seen  from 
WITHIN  THE  Bladder. — {After  Socin  and  Burckhardt.) 

The  large  submucous  veins  of  the  prostatic  urethra  become  much 
engorged  along  with  all  other  neighboring  veins,  and  by  a  sudden 
access  of  congestion  are  the  chief  cause  of  attacks  of  acute  retention  of 
urine.  They  may  bleed  spontaneously  at  times,  and  even  the  most 
gentle  catheterization  may  provoke  considerable  hemorrhage. 

Effects  on  the  Bladder. — Of  all  the  changes  produced  in  the  bladder 
by  enlargement  of  the  prostate  gland,  none  is  of  greater  importance 
than  the  formation  of  a  post-prostatic  pouch,  by  the  combined  elevation 
of  the  urethral  orifice  and  the  descent  of  the  vesical  floor.  This  is  a 
much  more  frequent  cause  of  residual  urine  than  is  the  ball-valve  action 
of  a  pedunculated  submucous  adenoma  blocking  the  urethra. 


Effects  on  the  Bladder 


113 


The  descent  of  the  vesical  floor  is  the  result,  not  the  cause,  as  Mr. 
Harrison  maintained,  of  the  enlarged  prostate.  Where  obstruction 
exists  to  the  evacuation  of  a  hollow  viscus,  it  is  surely  always  the  pre- 
ceding change,  and  the  dilatation  which  is  found  arises  from  vain  efforts 
to  expel  the  contents.  A  familar  example  of  this  is  seen  in  pyloric 
stenosis.  If  this  obstruction  is  overcome,  by  gastroenterostomy  or 
otherwise,  the  atonic  stomach  recovers  its  normal  physiological  action 
in  the  vast  majority  of  instances.  Similarly,  if  the  urinary  obstruction 
is  removed,  by  excision  or  even  by  suprapubic  drainage,  the  dilated  and 
^eble  bladder  will  recover,  if  the  condition  has  been  relieved  in  time. 


Fig.  50. — Cross     Section    of    Enlarged     Prostate. 
Note  the  line  of  cleavage  between  the  capsule  A,  A,  and  the  glandular  tissue.     The 
urethra  is  displaced  laterally  as  the  result  of  greater  involvement  of  one  lobe.     (Pilcher, 
in  Cabot's  Urology.) 

The  prostatic  obstruction  throws  increased  work  on  the  bladder, 
as  Mansell  Moullin  has  well  said,  and  when  i  t  is  no  longer  able  to  empty 
itself,  the  floor,  which  is  the  part  last  to  be  emptied  as  well  as  the 
weakest,  is  the  first  to  dilate.  When  this  stage  has  been  reached, 
every  effort  of  the  bladder  for  evacuation  only  serves  to  press  the  urine 
against  its  floor  and  to  increase  the  capacity  of  the  post-prostatic  pouch. 

The  shape  of  the  urethral  outlet  of  the  bladder  may  be  variously 


114  Clinical  Pathology 

altered  according  to  the  part  of  the  prostate  most  overgrown.  (See 
Section  on  Cystoscopy) .  It  is  usually  crescentic  in  outline,  the  concavity 
of  the  crescent  being  directed  towards  the  most  enlarged  part.  But 
if  the  prostate  enlarges  nearly  equally  in  both  its  supra-urethral  and 
infra-urethral  portions,  a  collar-like  projection  will  occur  into  the 
bladder  all  around  the  urethral  orifice.  This  form  of  enlargement 
has  been  graphically  compared,  both  in  appearance  and  in  feel,  to  the 
cervix  of  the  uterus,  the  urethra  being  placed  in  the  midst  of  a  hillock, 
like  the  cervical  canal  between  its  lips. 

If  the  lateral  lobes  enlarge  uniformly  and  tend  to  spread  away 
from  the  middle  line,  they  are  apt  to  raise  a  fold  of  tissue  taut  across 
the  vesical  orifice  of  the  urethra.  This  fold  may  be  composed  of 
mucous  membrane  alone,  or  may  have  a  varying  amount  of  sub- 
mucous tissue  in  it  as  well.  It  is  one  form  of  "bar  at  the  neck  of  the 
bladder,"  and  in  many  instances  is  a  serious  obstacle  to  catheterization. 

As  has  been  already  remarked,  an  isolated  adenomatous  mass, 
springing  from  the  prostate  beneath  the  neck  of  the  bladder  just 
posterior  to  the  urethral  orifice,  may  cause  the  inner  part  of  the  urethra 
to  become  Y-shaped. 

Very  great  impairment  of  the  urinary  function  may  result  when 
there  is  no  apparent  mechanical  obstruction.  In  such  cases  the  cause 
of  the  trouble  is  the  existence  of  a  fibrosis  in  the  neck  of  the  bladder 
and  the  prostate.  Such  processes,  the  result  of  long  preceding  con- 
gestion or  chronic  inflammation,  render  the  normally  soft  and  pliable 
vesical  outlet  firm  and  rigid,  so  that  the  prostatic  urethra  can  no 
longer  open  up  into  practical  continuity  with  the  bladder  during 
urination;  and  as  a  consequence,  obstruction  arises  from  the  im- 
mobility of  the  parts.  In  such  cases  the  prostate  may  be  little  or  not 
at  all  enlarged,  but  extremely  hard;  thus  furnishing  a  marked  example 
of  the  fibrous  class. 

While  the  most  prominent  changes  in  the  bladder  are  thus  seen 
to  occur  in  the  neighborhood  of  its  neck  and  the  trigone,  certain 
alterations  throughout  its  walls  occur  in  many  cases,  and  these  are  of 
nearly  equal  importance.  They  are  partly  the  result  of  the  effort 
to  overcome  the  obstruction,  and  partly  the  .result  of  the  chronic 
cystitis  which  almost  invariably  accompanies  prostatic  enlargement. 

The  increased  work  thrown  on  the  bladder  causes  first  an  hyper- 
trophy of  its  muscular  walls,  which  is  manifest  in  the  trabeculated 
appearance  of  its  mucous  surface.  If  the  obstruction  is  not  relieved 
in  time,  atony  ensues,  with  dilatation  of  the  bladder,  or  infective 


Efifects  on  the  Bladder  115 

interstitial  cystitis  and  fibroid  thickening  of  the  bladder  wall  with 
diminution  in  the  size  of  its  cavity.  In  cases  where  the  obstruction  is 
unreheved,  chronic  retention  occurs,  and  the  amount  of  residual  urine 
gradually  increases.     The  walls  of  the  bladder  may  then  become  much 


Fig.  51. — Enlargement  of  the  Lateral  Lobes  of  the  Prostate  Forming  between 
Them  a  Bar  at  the  Neck  of  the  Bladder. — {Watson.) 


ii6 


Clinical  Pathology 


distended  and  extremely  thin;  and  its  fundus  may  reach  to  the  umbil- 
icus or  above,  before  partial  relief  occurs  from  overflow.  Atony  of 
the  bladder  from  actual  disappearance  of  its  muscular  fibres  through 


Fig.    $2. — Atonic,  Dilated  Bladder,  from  Enlargement  of  the  Prostate  without 

Marked  Cystitis. 
(From  a  specimen  in  the  Mutter  Museum  of  the  College  of  Physicians  of  Philadelphia.) 

fatty  degeneration  may  thus  arise;  and  although  atony  so  extreme  as 
to  be  irremediable  is  no  longer  thought  to  be  very  frequent,  yet  the 
surgeon  should  bear  this  danger  in  mind,  and  see  that  his  patients  are 
relieved  of  their  retention  before  matters  have  gone  too  far. 


Effects  on  the  Kidneys  117 

But  the  bladder  may  not  dilate;  its  walls  may  become  much 
thickened,  corrugated  and  pouched;  its  cavity  may  even  contract, 
and  contain  only  a  few  cc.  of  urine,  necessitating  its  evacuation  every 
ten  to  fifteen  minutes.  As  the  muscular  walls  become  fibrous  they 
contract  on  the  contained  mucous  coat,  and  this  may  be  seen  bulging 
out  in  pouches  in  the  interstices  between  the  thickened  fibrous  bands, 
as  efforts  to  expel  the  urine  are  made.  These  herniated  pouches  may 
in  time  remain  permanently,  not  disappearing  even  when  the  bladder 
is  relaxed.  In  such  cases  not  only  may  residual  urine  collect  in  these 
pouches,  but  calcuU  may  form  in  them,  and  thus  much  increase  the  pain 
and  discomfort  of  the  patient.  The  presence  or  absence  of  dverticulae 
should  be  determined  before  attempting  prostatectomy.  Failure  to  dis- 
cover the  presence  of  a  large  diverticulum  may  lead  to  a  most  unfortu- 
nate outcome  in  the  otherwise  successful  operative  removal  of  an  enlarged 
prostate.  Owing  to  retention  within  the  sac  of  the  diverticulum  the 
amount  of  residual  urine  is  perhaps  only  sUghtly  reduced  after  operation 
and'  the  patient's  symptoms  are  relieved  only  in  part,  if  at  all. 

Careful  search  for  the  orifices  of  diverticula  should  be  a  part  of  the 
routine  cystoscopic  examination,  or  if  this  examination  is  for  any 
reason  omitted,  it  is  advisable  to  prepare  radiographs  of  the  bladder. 
Finally,  it  is  our  custom  at  the  time  of  suprapubic  operations  to  make 
a  careful  inspection  of  the  interior  of  the  bladder. 

The  changes  in  the  bladder  walls  the  result  of  cystitis '  differ 
in  no  respect  from  those  due  to  cystitis  from  other  causes.  Vesical 
catarrh  is  a  prominent  symptom,  and  the  viscid  ropy  mucus  adds 
to  the  urinary  obstruction.  The  mucous  membrane  is  highly  con- 
gested; it  may  be  ulcerated  in  places;  and  calcareous  deposits  are 
frequently  found  on  its  surface.  So  turgid  are  the  veins  that  it  is  the 
rule  for  some  degree  of  hematuria  to  be  developed  as  soon  as  the 
dladder  is  relieved  of  the  urinary  pressure. 

Where  infection  is  present,  it  is  probable  that  chronic  urinary  reten- 
tion so  extreme  as  to  produce  overflow  never  occurs;  but  that  the  acute 
pain  and  frequency  of  urination  claim  the  surgeon's  services  at  an 
earlier  stage  of  the  case.  It  is  therefore  in  the  infected  cases  that  the 
small  rugous  and  thickened  bladders  above  referred  to  are  oftenest 
encountered;  and  it  may  be  considered  a  question  whether  the  infection 
causes  the  contraction  primarily,  or  whether  this  occurs  only  because 
the  high  grade  of  cystitis  present  makes  reUef  to  obstruction  imperative 
before  dilatation  of  the  bladder  has  taken  place. 

Effects  on  the  Kidneys  and  Ureters. — From  the  presence  of  residual 


ii8  Clinical  Pathology 

urine  in  any  amount,  changes  may  be  observed  in  the  orifices  of  the 
ureters.  Normally  these  tubes  enter  the  bladder  wall  obliquely,  pass- 
ing through  the  vesical  coats  for  seven  to  ten  mm.;  and  they  discharge 
their  contents  into  the  bladder  in  driblets  or  in  spurts  at  intervals  of 
some  seconds.  But  as  the  bladder  becomes  distended  the  ureteral 
openings  are  compressed,  and  the  discharge  of  their  contained  urine 
becomes  more  difficult.  When  the  bladder  is  excessively  distended, 
and  its  wall  is  overstretched  in  all  its  parts,  the  ureteral  orifices  may 
become  constantly  patulous,  by  the  approximation  of  their  course 
through  the  bladder  walls  to  a  straight  hne.  Dilatation  of  the  ureters 
may  result. 

As  soon  as  the  pressure  in  the  ureters  becomes  increased,  a  damming 
up  of  urine  occurs  into  the  pelvis  and  calices  of  the  kidneys;  and  this 
change  in  pressure,  apart  from  any  infection,  is  soon  manifested  in  the 
behavior  of  the  kidneys  themselves.  Circulatory  disturbances  are 
produced  in  the  kidneys,  the  immediate  effects  of  which  are  not  accu- 
rately known;  but  from  the  observations  of  Cabot  it  is  evident  that  in 
their  early  stages  they  are  not  beyond  the  hope  of  cure.  Generally 
speaking,  it  is  pretty  sure  that  this  increased  pressure  alone,  even 
without  any  infection,  will  cause  the  production  of  fibrous  overgrowth 
in  the  kidneys,  as  well  as  an  increase  in  the  quantity  and  a  decrease 
in  the  specific  gravity  of  the  urine  excreted.  That  the  primary  change 
in  the  kidneys  is  probably  atrophy  of  the  secreting  structure,  while 
fibrous  hyperplasia  is  a  subsequent  occurrence,  has  long  been  an  ac- 
cepted theory.  The  infective  micro-organisms  are  usually  carried  to 
the  kidney  by  the  blood  or  by  the  lymph  vascular  systems,  but  direct 
extension  upward  beneath  the  mucosa  of  a  dilated  ureter  or  even  by 
way  of  the  lumen  is,  we  believe,  of  common  occurrence.  The  impor- 
tance of  renal  complications  is  discussed  at  greater  length  in  the  section 
devoted  to  prognosis. 

Where  infection  exists,  and  especially  where  the  vesical  orifices  of 
the  ureters  are  more  or  less  patent,  pyeUtis  and  surgical  kidneys  soon 
develop. 

Effects  on  the  Urine. — The  residual  urine  almost  invariably  becomes 
alkaline,  and  is  a  prolific  cause  of  cystitis..  Being  alkaline,  phosphatic 
or  mulberry  (oxalate  of  lime)  calculi  are  prone  to  form.  It  has  been 
estimated  that  nearly  one-fourth  of  all  patients  with  enlarged  prostate 
have  calculi  as  well.  The  calculus,  however,  being  usually  fixed  rather 
firmly  in  the  post-prostatic  pouch,  frequently  gives  no  characteristic 
symptoms,  and  is  difficult  of  detection  with  a  sound.  Especially  is 
this  the  case  where  a  calculus  forms  in  or  subsequently  becomes  lodged 


Effects  on  the  Urine 


IIQ 


Fig.    53. — Contracted,  Infected  Bladder,  with  Thickened  Walls  and  the  For- 
mation OF  Vesical  Sacculi,  from  Enlargement  of  the  Prostate  Accompanied  by 
Marked  Cystitis. 
(From  a  specimen  in  the  Mutter  Museum  of  the  College  of  Physicians  of  Philadelphia.) 


120  Clinical  Pathology 

in  one  of  the  pouches  already  alluded  to;  or  when  its  surface  becomes 
covered  with  mucus,  or  it  is  surrounded  by  prostatic  overgrowths. 
As  already  mentioned,  the  urinary  salts  may  be  deposited  in  calcareous 
crusts  over  the  entire  vesical  walls  giving  rise  to  encrusted  cystitis. 

When  chronic  cystitis  develops,  the  urine  presents  the  well-known 
characteristics  of  this  disease.  Shreds  of  mucus,  pus,  clots  of  blood, 
and  various  crystals  may  be  found.  Ammoniacal  decomposition  is 
frequent.  The  colon  bacillus,  imparting  to  the  urine  its  characteristic 
odor,  may  be  the  infecting  medium;  it  is  not  impossible  for  this  germ 
to  gain  entrance  to  the  bladder  directly  from  the  intestinal  tract,  though 
probably  its  more  usual  avenue  of  approach  is  through  the  urethra. 
Streptococci,  staphylococci,  and  other  micro-organisms  are  also 
found. 

The  pus,  the  mucus,  and  especially  the  blood  clots,  are  frequent  causes 
of  stammering  in  micturition;  and  as  they  are  sucked  into  the  eye  of 
the  catheter  impart  to  the  hand  a  readily  recognized  sensation.  The 
blood  may  come  from  spontaneous  rupture  of  engorged  veins,  or  from 
trauma  by  a  calculus  or  a  catheter.  At  times  the  clots  are  found 
nearly  filling  the  cavity  of  the  bladder. 

When  the  kidneys  become  affected  the  urine  becomes  correspond- 
ingly altered,  as  seen  in  the  early  stages  of  interstitial  nephritis  from 
other  causes.  The  quantity  passed  in  twenty-four  hours  may  reach 
2700  to  3000  cc,  or  even  more;  the  specific  gravity  will  show  a  propor- 
tionate decrease;  and  albumen  and  tube  casts  may  be  detected.  It 
should  not  be  overlooked,  however,  that  renal  disease  may  have  long 
antedated  the  prostatic  trouble. 

Effects  on  Urination.^ — Such  widespread  and  serious  changes  through- 
out the  urinary  apparatus  cannot  fail  to  produce  marked  changes  in 
the  manner  and  the  power  of  micturition.  These  will  be  more  fully 
discussed  under  the  heading  of  symptomatology,  but  it  is  well  to  recall 
briefly  in  this  place  the  modus  o/?6rawf//;  Residual  urine  causes  cystitis; 
cystitis  causes  frequent  desire  for  urination;  frequent  urination  increases 
the  existing  congestion;  this  in  turn  may  bring  on  retention  of  urine; 
catheterization  is  resorted  to,  once  or  oftener;  infection  is  very  liable  to 
occur  in  a  bladder  already  so  inflamed;  the  retention  and  the  infection 
of  the  urine  produce  circulatory  disturbances  in  the  kidney;  the  quantity 
of  the  urine  is  increased,  and  a  vicious  circle  is  established,  which,  unless 
the  primary  cause,  urinary  obstruction,  be  removed,  will  quickly  affect 
the  patient's  general  health. 

The  dilatation  of  the  bladder,   and   consequent  weakness  of  its 


EfiFects  on  the  Rectum  121 

walls,  causes  two  well-known  symptoms— feeble  power  of  expulsion, 
and  slowness  in  completing  the  urinary  act;  while  finally  the  inability 
of  the  vesical  neck  to  act  properly,  and  the  interference  with  the  muscles 
around  the  membranous  urethra,  cause  the  last  portion  of  urine  to  be 
voided  in  dribbles,  no  power  remaining  of  evacuating  it  in  spurts. 

Effects  on  the  Rectum. — Enlargement  of  the  prostate,  as  is  well 
known,  is  very  apt  to  be  accompanied  by  hemorrhoids  and  prolapsus 
ani.  These  affections  may  be  produced  by  the  prostatic  hyper- 
trophy, or  they  may  be  due  to  an  independent  though  concurrent 
cause. 

Venous  engorgement  of  the  prostate  and  the  vesical  neck  is  one  of 
the  main  causes  of  sudden  urinary  retention,  as  mentioned  above; 
and  such  venous  engorgement,  when  prolonged  or  when  recurring  fre- 
quently, soon  leads  to  a  varicose  condition  of  the  prostatic  plexus. 
Under  these  conditions  incompetency  of  the  valves  in  this  plexus 
develops,  and  the  blood  regurgitates  through  communicating  branches, 
and  becomes  dammed  up  in  the  internal  pudic  and  the  middle  and 
inferior  hemorrhoidal  veins.  Since  all  these,  as  well  as  the  prostatic 
plexus  itself,  empty  into  the  internal  iliac  vein,  no  real  relief  to  the  ven- 
ous obstruction  ensues;  but  hemorrhoids  develop,  and  by  their  pain 
add  to  the  misery  of  the  patient.  Some  slight  relief  might  occur  from 
vascular  overflow  into  the  superior  hemorrhoidal  veins;  but  as  these 
are  radicles  of  the  portal  system,  which  has  no  valves,  and  which  is 
very  apt  to  be  already  congested  or  obstructed  in  persons  who  have 
reached  the  prostatic  age,  the  superior  hemorrhoidal  veins  are  only  too 
often  varicose  even  before  the  middle  and  inferior  become  so.  Phle- 
boliths  are  common  in  the  prostatic  plexus. 

Not  only  does  prostatic  enlargement  affect  the  rectum  in  this 
manner  by  producing  hemorrhoids,  but  it  may  seriously  obstruct  the 
rectal  canal  when  the  gland  is  much  enlarged  in  this  direction.  The 
act  of  defecation  is  rendered  difficult  and  painful  by  this  enlargement ; 
constipation  is  favored,  and  this  again  reacts  for  evil  by  increasing  the 
tendency  to  piles. 

Prolapsus  is  Hable  to  follow  in  the  wake  of  these  other  troubles, 
both  from  the  straining  in  the  efforts  to  empty  the  bladder,  and  from 
the  hemorrhoidal  condition  of  the  rectum  itself. 

Pelvic  congestion  is  favored  by  nearly  every  circumstance 
—especially  by  the  condition  of  the  patient's  heart,  kidneys,  and 
liver,  all  of  which  have,  as  a  rule,  begun  to  show  the  fibrosis  of  age ; 
as  well  as  by  the  prostatic  changes  produced  by  whatever  cause. 


122  References 

REFERENCES  (CHAPTER  VI) 

Cabot:  Boston  Med.  and  Surg.  Jour.,  1903,  ii,  559. 

Finger:  All.  Wien.  med.  Ztschr.,  1893. 

Keyes:  Amer.  Jour.  Med.  Sciences,  1898,  cxvi,  125. 

Harrison:  Quoted  by  Ashhurst:  Ashhurst's  Internat.  Encyl.  of  Surgery,  New  York,  1888, 

2d  ed.,  vi,  p.  265. 
MacCallum,  A  Text  Book  of  Pathology.,  W.  B.  Saunders  and  Co.      1916. 
Moullin:  Enlargement  of  the  Prostate,  London,  1899,  2d  ed.;  1904,  3d  ed. 
Vignard:  Quoted  by  Guyon:  Legons,  sur  les  Maladies  des  Voies  Urinaires,  Paris,  1903,  46 

ed.,  i,  passim. 


CHAPTER  VII 
SYMPTOMS:  SUBJECTIVE  AND  OBJECTIVE 

Subjective  Symptoms. — Not  every  patient  with  enlargement  of  the 
prostate  presents  symptoms  of  his  malady.  Only  about  one  in  every 
seven  who  has  an  enlarged  prostate  suffers  from  it;  and  even  among 
the  number  who  do  develop  symptoms  there  are  many  in  whom  these 
begin  so  insidiously  that  the  patients  will  perhaps  be  unaware  of  any 
deviation  from  the  normal  until  acute  retention  of  urine  occurs  from 
some  access  of  obstruction,  or  until  overflow  relieves  the  unperceived 
chronic  retention.  The  affection,  on  the  other  hand,  while  gradual  in 
onset,  may  yet  make  its  presence  felt  by  symptoms  which  arrest  the 
patient's  attention  from  the  first. 

Some  change  in  the  urinary  function  is  almost  invariably  the 
earliest  change,  and  usually  consists  in  an  increased  frequency  of  mic- 
turition. This,  if  it  occurred  only  during  the  day,  might  easily  escape 
notice;  but  since  it  is  present  at  night  as  well,  and  compels  the  patient 
to  arise  once  or  oftener  from  his  sleep,  is  a  change  which  is  very  soon 
observed,  and  for  which  an  explanation  is  usually  promptly  sought. 
Especially  with  younger  patients  is  this  true;  among  the  old  a  not 
unnatural  idea  exists  that  frequency  of  urination  is  one  of  the  signs  of 
age,  and  is  therefore  rather  to  be  anticipated. 

Frequency  of  urination  is  due  mainly  to  two  causes :  first  and  fore- 
most, because  the  congestion  or  inflammation  of  the  vesical  neck  and 
the  parts  around  the  prostate  renders  the  bladder  more  sensitive 
to  the  presence  of  urine,  and  hence  less  able  to  support  a  large  volume 
of  fluid;  and,  secondly,  because  residual  urine  lessens  the  capacity  of  the 
bladder,  which  as  a  consequence  reaches  its  usual  grade  of  distention 
at  shorter  intervals.  Besides  these  factors,  the  quality  of  the  urine  is 
often  exceedingly  irritating,  and  so  its  expulsion  is  demanded  more 
frequently. 

Many  authors  have  taught  that  the  frequency  of  urination  is 
greater  at  night  than  during  the  day;  but,  apart  from  the  lack  of 
reason  for  this  phenomenon,  we  doubt  its  being  a  fact.  Greater  stress 
is  laid  upon  nocturnal  frequency  by  the  patient,  and  consequently  in 
many  cases  by  the  surgeon,  merely  because  it  arrests  the  attention 

123 


124  Symptoms 

sooner  than  increased  frequency  of  urination  by  day.     A  man  may 
wash  his  hands  eight  or  ten  times  during  the  day,  and  think  nothing  of 


Fig.  54. — Dilatation  of  the   Ureters  and   Hydronephrosis   from  Long-standing 

Prostatic  Obstruction. 
(From  a  specimen  in  the  Museum  of  the  Pennsylvania  Hospital.) 

it;  but  if  he  awakes  during  the  night  with  an  irresistible  desire  to  get 
up  and  wash  his  hands,  he  would  be  very  sure  to  remember  the  fact 


Subjective  Symptoms  125 

in  the  morning,  and  to  seek  an  explanation.  This  is  an  extreme  com- 
parison, but  serves  to  show  why  more  importance  is  attached  to  noc- 
turnal frequency,  than  to  that  occurring  during  the  day.  These 
patients  are  not  inclined  to  urinate  oftener  while  recumbent  in  day-time, 
so  the  horizontal  position  cannot  be  given  as  a  cause  for  greater  fre- 
quency by  night.  Sleep  may  possibly  be  the  factor  of  greatest  impor- 
tance, by  lessening  the  power  of  inhibition  over  the  involuntary  sphinc- 
ter, and  by  unconsciously  increasing  the  resistance  of  the  voluntary 
sphincter:  thus  when  the  patient  finally  wakes,  his  bladder  is  fuller, 
because  a  longer  interval  has  elapsed  since  it  was  last  emptied,  than  is 
the  case  during  the  day;  and  after  this  first  sound  sleep  of  a  few  hours, 
the  bladder  has  been  rendered  so  irritable  by  overdistention  that  calls 
to  urinate  occur  with  greater  frequency  during  the  remainder  of  the 
night.  This  is  given  as  a  possible  explanation  by  Moullin;  and  it 
appears  to  be  a  fact  that  the  first  interval  at  night  is  the  longest. 
Other  explanations  of  nocturnal  frequency  have  been  given,  such  as 
sexual  emotions  during  sleep;  but  it  is  probable  that  these  are  as  much 
a  consequence  as  a  cause. 

Of  course,  when  cystitis  develops  this  of  itself  causes  the  desire 
for  urination  to  be  more  frequent;  and  where  ulceration  or  fissure  of 
the  bladder  exists,  the  vesical  tenesmus  may  be  constant  and  un- 
controllable. 

The  patient  is  likewise  unable  to  expel  the  urine  with  his  accustomed 
force.  Starting  the  stream  is  difficult,  much  straining  being  required, 
because  there  is  both  increased  obstruction  and  decreased  expulsive 
power.  When  started,  the  stream  does  not  spurt  forth  in  the  nor- 
mal parabolic  curve,  but  tends  to  drop  vertically  from  the  meatus. 
A  longer  time  than  usual  is  required  to  pass  the  urine,  although 
a  smaller  quantity  than  normal  is  passed,  since  the  intervals  are  less 
and  some  residual  urine  remains.  The  stream  is  not  smaller  than  in 
health,  unless  stricture  causes  it  to  be  so. 

As  the  act  of  urination  draws  to  a  close,  the  urine  dribbles  involun- 
tarily. It  will  thus  often  wet  the  patient's  shoes;  so  that  if  there  is 
much  sediment  present,  these  spots  on  drying  will  be  incrusted  with 
salt;  from  this  fact  alone  a  tentative  diagnosis  may  be  made.  The 
cause  of  the  dribbling,  without  the  power  being  present  of  evacuating 
the  last  drops  in  spurts,  probably  lies  in  the  impaired  contractility  of 
the  bladder,  which  fails  to  send  forward  into  the  membranous  and  the 
bulbous  urethra  a  sufficient  quantity  of  urine  for  the  voluntary  mus- 
cles to  contract  upon.     The  prostatic  urethra,  moreover,  is  unable  to 


126  Symptoms 

put  itself  into  physiological  continuity  with  the  bladder,  and  acting  as 
a  more  or  less  rigid  tube,  interferes  with  the  normal  flow. 

Intermittent  urination  has  been  described  as  present  in  some 
cases,  but  is  very  rare.  It  may  be  due  to  the  ball-valve  action  of  a 
prostatic  outgrowth,  which  is  more  tightly  forced  against  the  vesical 
outlet  the  more  forcefully  the  .bladder  contracts,  and  which  permits 
urination  only  when  it  is  floated  back  from  the  orifice  of  the  urethra, 
during  intervals  of  straining.  If  not  due  to  such  a  cause  as  this,  the 
ordinary  "stammering  with  the  urinary  organs,"  as  Sir  James  Paget 
termed  it,  affords  a  sufficient  explanation.  The  presence  of  a  calculus 
may  also  act  in  this  way. 

Retention  of  urine  is  observed  by  the  patient  only  when  acute, 
or  ■  when  the  chronic  form  is  accompanied  by  overflow.  By  far 
the  most  frequent  cause  of  acute  retention  in  these  cases  is  an  access 
of  congestion  in  the  vesical  neck.  A  man  who  very  likely  had  thought 
himself  previously  perfectly  healthy  will  attend  some  pleasure  party, 
eat  and  perhaps  drink  more  than  he  is  in  the  habit  of  doing,  be  exposed 
to  draughts,  become  overheated,  or  in  some  way  commit  an  indiscre- 
tion; and  on  his  return  home  will  find  himself  unable  to  pass  his  urine. 
When  relieved  by  catheterization,  a  similar  event  may  not  occur  for 
months  or  years,  or  perhaps  never  again. 

Overflow  from  retention  is  in  some  instances  the  symptom  which 
first  attracts  the  patient's  attention.  When  the  bladder  has  reached 
its  limit  of  distensibility,  as  soon  as  any  urine  is  received  from  the 
ureters,  an  equal  amount  must  be  discharged  by  the  urethra.  This 
involuntary  leakage  may  be  noticeable  first  only  at  night,  when  the 
influence  of  the  will  is  withdrawn,  or  by  day  only  during  the  effort 
of  lifting  some  heavy  object,  in  stooping  to  pick  something  from  the 
floor,  or  during  defecation — all  these  acts  necessitating  contraction  of 
the  abdominal  muscles,  and  hence  diminution  in  bladder  capacity.  At 
later  stages  this  overflow  becomes  a  constant  symptom,  and  unless 
relieved  the  patient  must  wear  a  urinal,  or  have  his  clothing  constantly 
wet.  The  odor  attendant  upon  this  condition  will  frequently,  in  the 
poorerclass  of  patients,  at  once  direct  attention  to  the  true  state  of  affairs. 

As  previously  pointed  out,  this  symptom  is  much  more  frequent 
where  there  is  no  cystitis.  The  probable  explanation  is  that  no 
catheter  has  ever  been  passed  to  relieve  the  bladder  of  its  residual 
urine,  and  to  prevent  its  walls  from  losing  their  muscular  tone  through 
overdistention;  and  that  since  no  catheter  has  been  passed,  no  cystitis 
has  developed. 


Urinary   Retention  127 

Incontinence  of  urine  is  extremely  unusual.  It  has  often  been 
supposed  to  be  present  when  the  true  condition  was  that  just  de- 
scribed— overflow  from  retention.  If  true  incontinence  of  urine  does 
exist,  it  may  readily  be  determined  by  catheterization,  when  the 
bladder  will  be  found  empty.  It  is  probably  due,  when  present,  to  a 
form  of  prostatic  overgrowth  which  keeps  the  vesical  orifice  of  the 
urethra  constantly  patent,  and  to  inability  of  the  voluntary  sphincter 
properly  to  contract.  In  the  abnormal  condition  where  urine  is  con- 
stantly in  the  prostatic  portion  of  the  urethra,  a  constant  effort  of  the 
will  is  required  to  avoid  its  passage.  Hence,  even  if  the  voluntary 
sphincter  can  act  normally  during  the  day-time,  incontinence  will  be 
present  in  these  cases  during  sleep,  except  where  the  elastic  resistance 
of  the  urethra  is  stronger  than  the  contraction  of  the  bladder  walls. 
But,  as  a  rule,  when  true  incontinence  occurs  at  all,  it  is  present 
throughout  the  twenty-four  hours. 

The  symptoms  of  cystitis  arising  in  a  patient  with  enlarged  prostate 
are  the  same  as  those  in  other  cases  of  cystitis,  and  do  not  require 
extended  mention  in  a  work  of  this  kind.  Cystitis  in  these  cases  is 
usually  caused  by  catheterization.  It  is  possible  for  bacteria  to  gain 
entrance  to  the  bladder  in  other  ways,  such  as  through  the  kidneys, 
directly  from  the  rectum,  and  by  extension  along  the  urethra. 

Urination  which  was  frequent  before,  becomes  doubly  so  when 
cystitis  develops;  tenesmus  is  more  pronounced,  and  the  relief  obtained 
by  the  partial  evacuation  is  slight.  A  heaviness  and  burning  may  be 
felt  in  the  perineum;  suprapubic  pain  may  be  marked;  or  the  most 
infernal  of  all  tortures,  the  burning,  boring,  uncontrollable  pain  in  the 
neck  of  the  bladder,  may  render  the  patient  nearly  insane.  Pus,  mucus, 
and  blood  may  all- be  observed  in  his  urine. 

Hematuria,  though  not  one  of  the  most  prominent  symptoms,  is 
met  with  sufficiently  often  to  command  the  surgeon's  particular  atten- 
tion. It  may  be  due  to  spontaneous  rupture  of  varicose  urethral  or 
vesical  veins,  or  it  may  be  produced  in  certain  instances  by  the  most 
gentle  catheterization,  or  it  may  come  from  ulceration  due  to  pro- 
longed cystitis  or  to  calculus.  In  cases  of  marked  obstruction  the 
patient  after  persistent  straining  may  relieve  himself  of  only  a  few  drops 
of  blood.  In  such  cases  the  blood  probably  comes  from  congested 
veins.  If  the  blood  is  mixed  with  the  urine  as  it  flows,  it  probably  comes 
from  the  prostate  or  from  the  neck  of  the  bladder,  and  may  flow  from 
an  ulcer  or  from  a  ruptured  blood  vessel.  If  it  flows  only  at  the  close 
of  urination,  and  particularly  if  it  is  clotted,  it  is  apt  to  come  from  the 
post-prostatic  pouch  of  the  bladder. 


128  Symptoms 

Symptoms  of  renal  failure  my  arise  at  various  stages  of  the  disease. 
Nephritis  may,  of  course,  be  an  independent  affection;  but  if  not  already 
present,  is  usually  manifest  very  soon  after  the  quantity  of  residual 
urine  becomes  great,  or  when  infection  of  the  bladder  causes  retrograde 
pyelitis.  The  patient  may  notice  that  he  not  only  passes  urine  more 
frequently,  but  that  the  total  quantity  passed  is  greater,  and  that  he  is 
unaccountably  thirsty.  This  increase  in  quantity  is  one  of  the  earliest 
evidences  of  impairment  of  the  kidneys,  and  should  be  carefully  noted. 
If  complete  retention  occurs  in  such  cases,  uremia  may  rapidly  super- 
vene, from  the  inability  of  the  kidneys  in  their  diseased  state  to  excrete 
under  increased  pressure  the  toxic  matters  whose  retention  in  the  blood 
gives  rise  to  the  well-known  symptoms :  confusion  and  anxiety  of  mind, 
dyspnoea,  dry  burning  skin,  feverish  eye,  parched  tongue,  urinous  odor 
to  the  breath,  hiccough  and  vomiting,  somnolence  and  coma,  convul- 
sions, and  death.  If  pyelitis  is  present  from  infection,  irregularly 
recurring  chills,  with  fever  and  sweats,  may  be  added  to  the  above 
train  of  symptoms. 

Closely  following  upon  the  heels  of  renal  involvement,  certain 
cardiac  symptoms  may  appear — slight  dropsy  in  the  ankles  or  the 
hands,  shortness  of  breath  on  exertion;  palpitation;  loss  of  appetite 
from  gastric  congestion;  and  other  symptoms  too  generally  recognized 
to  need  repetition  here. 

Sexual  power  is  often  lost  if  the  prostatic  disease  is  far  advanced; 
in  earlier  stages  intercourse  may  be  painful,  pain  being  marked  espe- 
cially after  completion  of  the  act.  Not  infrequently  the  sexual  appe- 
tite is  abnormally  active,  and  distressing  priapism  may  occur.  - 

If  the  prostate  enlarges  much  towards  the  rectum,  certain  additional 
symptoms  may  be  noted  by  the  patient.  Both  constipation  and  obsti- 
pation may  arise;  and  the  constant  straining  to  urinate  or  defecate  may 
produce  hemorrhoids,  and  even  prolapsus  ani,  as  in  the  case  of  children 
straining  on  account  of  vesical  calculus.  It  is  in  this  form  of  enlarge- 
ment, too,  that  the  fullness  and  uncomfortable  feeling  in  the  perineum, 
so  often  complained  of,  are  chiefly  found. 

If  calculi  form  in  the  bladder,  some  special  symptoms  of  this  malady 
may  be  noted;  but,  as  a  rule,  they  are  subordinated  to  the  peculiar 
prostatic  symptoms,  since  the  stone  is  held  fairly  firmly  in  the  post- 
prostatic  pouch,  or  in  the  sac  of  a  diverticulum. 

To  attempt  clinical  pictures  of  patients  suffering  from  enlargement 
of  the  prostate,  by  dividing  the  disease  into  certain  stages,  is  a  rather 
arduous  task,  since  the  duration  of  any  one  symptom  or  set  of  symptoms 


Objective  Symptoms  129 

varies  exceedingly  in  different  individuals.  Perhaps  as  just  an  appre- 
ciation as  any  of  this  view  of  prostatic  enlargement  may  be  reached  by 
grouping  the  patients  into  three  classes,  in  the  first  of  which,  the  earliest 
stage,  may  be  placed  those  patients  whose  chief  complaint  is  nocturnal 
frequency  of  urination;  in  the  second  stage  those  patients  who  suffer 
occasionally  from  complete  retention,  but  whose  cystitis  is  insignificant, 
and  whose  general  health  is  fairly  good;  and  in  the  third  class  those 
wretched  individuals  whose  retention  is  nearly  absolute  or  quite  so, 
who  depend  entirely  on  catheterization,  whose  kidneys  are  markedly 
diseased,  and  whose  general  health  is  on  the  verge  of  collapse. 

Some  patients  will  remain  in  the  first  stage  all  their  lives;  some  will 
within  a  few  months  pass  into  the  second  stage;  and  others  will  seem- 
ingly jump  at  once  from  the  first  to  the  third  stage  with  scarcely  an 
appreciable  sojourn  in  the  second. 

Some  patients,  on  the  other  hand,  will  never  be  conscious  of  having 
passed  through  the  first  stage,  but  will  first  be  impelled  to  seek  medical 
aid  for  sudden  retention  of  urine;  and  may  then,  if  fortunate,  return 
to  the  first  stage  and  remain  there  all  their  lives.  In  many  instances 
patients  who  reach  the  second  stage  without  having  been  aware  of  the 
first  will  remain  in  the  second  stage  throughout  their  lives;  but  in  very 
rare  instances  only  do  patients  pass  at  once  from  a  Hfe  of  seemingly 
perfect  health  to  one  of  absolute  and  complete  catheterism. 

The  surgeon  should,  above  all  things,  bear  in  mind  that  a  positive 
diagnosis  of  enlargement  of  the  prostate  can  never  be  made  from  the 
symptoms  alone:  a  physical  examination  is  absolutely  essential. 

Objective  Symptoms — ^Physical  Examination. — When  a  patient, 
suspected  from  the  symptoins  he  describes  to  be  suffering  from  enlarge- 
ment of  the  prostate  gland,  presents  himself  to  the  surgeon,  the  first 
and  most  important  physical  sign  to  be  looked  for  is  the  presence  of 
a  hypogastric  tumor,  with  the  characteristics  of  a  distended  bladder. 
Important  as  it  is  in  all  cases,  it  is  above  all  in  those  patients  who  have 
been  afflicted  with  chronic  urinary  retention  and  over-flow  that  this 
precaution  is  indispensable.  In  such  patients  the  hasty  introduction 
of  a  catheter  may  cause  immediate  syncope,  from  the  decrease  of  intra- 
abdominal pressure,  and  may  in  a  few  days  lead  to  death  from  renal 
congestion  and  uremia.  To  plunge  a  catheter  regardlessly  into  such  a 
bladder  in  one's  office,  or  at  a  hospital  dispensary,  where  the  patients 
are  not  provided  with  the  requisite  facilities  for  proper  after-treatment, 
will  ever  remain  a  most  dangerous  and  unsurgical  procedure. 

Having  detected  such  a  hypogastric  tumor,  or  having  ascertained 


130  Symptoms 

its  absence,  the  patient  should  next  be  requested  to  urinate.  We  may 
then  observe  the  facility,  or  the  difficulty,  with  which  he  starts  the 
stream;  the  force  with  which  it  is  expelled  from  the  bladder;  its  size, 
as  indicative  of  stricture  or  not;  whether  it  is  suddenly  interrupted  at 
any  time,  showing  the  possible  ball-valve  action  of  a  pedunculated 
''middle  lobe,"  or  of  a  calculus;  and  whether  he  concludes  the  urinary 
act  in  the  normal  manner,  or  if  the  last  portions  dribble  out  of  his 
urethra  without  voluntary  control.  From  a  strict  attention  to  these 
details — and  no  details  are  too  insignificant  in  urinary  affections — much 
may  be  learned  that  will  prove  of  subsequent  interest.  The  quantity 
of  the  urine  thus  passed  is  then  to  be  measured,  and  a  portion  of  it 
preserved  for  chemical  and  microscopical  examination.  Its  color, 
odor,  and  the  presence  or  absence  of  sediment,  as  roughly  gauged  by 
the  eye,  will  be  of  immediate  use  to  us  in  approximating  the  condition 
of  the  bladder  and  the  kidneys.  By  learning  the  interval  since  the 
last  urination,  and  knowing  the  quantity  just  passed,  we  may  form  an 
estimate  of  the  total  quantity  passed  in  twenty-four  hours;  and  if  the 
amount  of  residual  urine  is  fairly  constant,  this  quantity  serves  as  a 
rough  index  to  the  action  of  the  kidneys.  If  a  patient  passes  120  cc.  of 
urine  only  every  three  or  four  hours,  either  the  normal  amount  is 
not  excreted  by  the  kidneys,  or  else  the  quantity  of  residual  urine  is 
rapidly  increasing.  If,  on  the  other  hand,  from  fifteen  to  thirty  cc.  is 
passed  every  ten  or  fifteen  minutes,  the  patient's  kidneys  will  be  excret- 
ing from  150  to  4500  cc.  of  urine  daily,  and  retention  with  overflow 
probably  exists. 

If  it  appears  that  the  bladder  is  not  distended,  it  will  then  be  proper 
and  convenient  to  insert  a  catheter  to  determine  the  amount  of  the 
residual  urine,  and  to  aid  in  palpation  of  the  prostate.  For  these 
manipulations   the  patient  should  be  in   the  horizontal  position. 

In  many  cases  the  surgeon  will  be  forced  to  try  several  catheters 
before  he  succeeds  in  reaching  the  bladder.  Where  possible,  for  diag- 
nostic purposes  only,  we  prefer  a  bicoude  catheter,  about  number 
twenty  of  the  French  scale.  For  the  first  examination  metal  instru- 
ments present  many  obvious  advantages,  such  as  the  ease  with  which 
they  are  sterilized  by  being  passed  through  the  flame  of  an  alcohol  lamp, 
or  by  igniting  alcohol  which  has  been  poured  over  them ;  and  finally, 
what  is  of  great  importance,  that  they  serve  as  an  exploratory  sound 
both  in  the  urethra  and  within  the  bladder.  We  have  little  doubt 
that  many  a  soft-rubber  catheter  which  is  sterile  when  taken  into  the 
hands,  oftentimes  becomes  foully  contaminated  by  the  manipulations 


Objective  Symptoms  131 

that  are  necessary  for  its  insertion  into  and  passage  through  the  urethra. 
In  the  small  group  of  cases  in  which  cystoscopic  examination  is  for  any 
reason  inadvisable,  we,  therefore,  prefer  to  make  the  urethral  explora- 
tion for  diagnostic  purposes  with  a  metal  instrument. 

As  the  catheter  passes,  the  surgeon  should  note  the  presence  or 
absence  of  strictures,  any  deviation  from  the  normal  line  of  the  sub- 
pubic urethra,  the  height  to  which  its  vesical  orifice  is  raised,  and 
lastly  the  distance  from  the  urinary  meatus  at  which  urine  first 
begins  to  flow. 

In  passing  the  catheter  the  following  facts  favor  the  diagnosis  of 
enlarged  prostate :  If  it  is  found  that  the  shaft  has  to  be  unduly  de- 
pressed between  the  patient's  legs  before  any  urine  flows,  showing 
that  the  vesical  orifice  of  the  urethra  is  raised;  if  the  urinary  distance 
(that  from  the  meatus  to  the  point  at  which  urine  commences  to  flow 
through  the  catheter)  is  increased  above  twenty  centimetres;  if  the 
catheter  deviates  towards  one  or  the  other  side  as  it  passes  through 
the  prostatic  urethra,  showing  an  inequality  in  size  of  the  two  lateral 
lobes,  or,  finally,  if  an  obstruction  to  the  passage  of  the  catheter  is 
encountered  at  a  distance  of  more  than  about  seventeen  centimetres 
from  the  meatus,  showing  that  the  obstruction  is  not  due  to  strictures, 
which  are  never  present  in  the  prostatic  urethra. 

The  surgeon  should  not  be  deceived  into  thinking  the  bladder 
has  been  reached  when  a  small  quantity  of  urine  is  evacuated  from  an 
enlarged  prostatic  urethra.  It  will  be  remembered  that  this  portion 
of  the  urethra  may  at  times  hold  as  much  as  thirty  to  sixty  cc.  of  urine. 

The  bladder  having  been  reached  with  the  catheter,  the  residual 
urine  will  flow.  If  it  flows  through  the  catheter  without  effort  on  the 
patient's  part,  it  indicates  a  fairly  good  vesical  tone;  but  if  even  with 
the  aid  of  his  abdominal  muscles  the  patient  cannot  expel  the  residual 
urine,  and  only  by  suprapubic  pressure  with  the  surgeon's  hand  can 
this  be  made  to  flow,  it  is  evident  that  atony  of  the  bladder  is  far 
advanced. 

The  amount  and  the  character  of  the  residual  urine  will  then 
be  noted.  From  it  much  more  accurately  than  from  that  passed 
voluntarily  can  the  state  of  the  bladder  be  inferred.  Some  sedi- 
ment will  almost  invariably  be  evacuated.  If  much  is  present, 
it  is  probable  that  catheterization  has  often  been  resorted  to  before, 
and  that  a  more  or  less  marked  cystitis  exists.  Clots  of  blood  are 
frequently  found.  Possibly  some  calcareous  sediment  will  exist. 
The  odor  of  the  residual  urine  is  usually  ammoniacal.     But  apart 


132  Symptoms 

from  the  fact  of  there  being  residual  urine,  its  quality  does  not  aid  the 
diagnosis  of  enlarged  prostate,  merely  showing  the  grade  of 
cystitis  present. 

It  is  well  to  inject  a  few  cc.  of  warm  boric  acid  or  saline  solution, 
to  hold  the  walls  of  the  bladder  away  from  the  beak  of  the  catheter.  By 
the  resistance  encountered  during  the  injection  an  idea  of  the  condition 
of  the  bladder  walls — whether  dilated  or  contracted — can  be  obtained. 

Using  the  metallic  catheter  with  all  gentleness,  then,  as  a  sound, 
we  can  detect  the  approximate  amount  of  intravesical  enlargement  of 
the  prostate;  the  quality  of  the  bladder  walls,  whether  flabby  and 
dilated,  or  thick,  rugous,  and  pouched;  the  existence  of  calcareous 
crusts  on  the  surface  of  the  bladder,  and  of  a  calculus  in  the  post- 
prostatic  pouch,  or  in  one  of  the  vesical  sacculi. 

The  surgeon  should  next,  without  removing  the  catheter,  introduce 
a  finger  of  the  left  hand  into  the  patient's  rectum.  In  doing  this  it  is 
usually  more  convenient  to  stand  on  the  patient's  left  side,  and  to 
manipulate  the  catheter  or  the  sound  with  the  right  hand.  The 
intravesical  instrument  is  to  be  regarded  merely  as  a  very  long  finger, 
and  the  amount  of  information  that  can  be  gained  through  it  by  an 
experienced  surgeon  will  be  a  matter  of  astonishment  to  the  tyro. 

The  examining  finger  should  not  be  thrust  blindly  and  suddenly 
into  the  rectum — such  a  procedure  is  both  painful  and  dangerous, 
since  hemorrhoids  with  considerable  proctitis  may  be  present;  but  by 
a  very  gradual  and  gentle  boring  motion  the  finger  may  be  insinuated 
so  as  to  cause  the  patient  very  little  discomfort.  As  the  finger  passes 
the  sphincter  we  can  feel  the  catheter  in  the  bulbous  urethra,  then  can 
trace  it  back  into  the  membranous  urethra,  but  in  case  the  prostate  is 
enlarged  it  will  be  impossible  to  trace  it  further.  The  finger  next 
encounters  the  prostate  in  the  anterior  rectal  wall,  and,  passing  to 
either  side,  towards  the  ischial  tuberosities,  the  outline  of  the  enlarged 
lateral  lobes  can  be  detected.  In  most  cases  it  will  require  a  long 
finger  to  reach  well  beyond  the  enlarged  prostate,  and  to  feel  the  tip  of 
the  catheter  in  the  retro-prostatic  pouch;  but  this  should  always 
be  attempted,  as  we  thus  obtain  a  very  much  more  accurate  idea  of  the 
size  and  shape  of  the  prostate;  and  where  the  beak  of  the  catheter  is 
not  long  enough  to  reach  the  floor  of  the  pouch,  it  may  be  possible  to 
elevate  this  by  the  finger  in  the  rectum,  and  thus  to  detect  a  calculus 
which  might  otherwise  have  escaped  notice.  By  directing  the  patient 
to  close  his  mouth  and  "bear  down,"  the  prostate  may  be  forced  into 
reach  of  the  finger  even  when  very  much  enlarged. 


Rectal  Examination 


^33 


M 


134  Symptoms 

Before  withdrawing  the  finger  the  state  of  the  seminal  vesicles 
should  be  examined  if  they  are  within  reach.  The  existence  of  high 
internal  hemorrhoids  can  also  be  determined. 

If  it  has  been  impossible  satisfactorily  to  examine  the  rectal 
relations  of  the  prostate  on  account  of  its  size  or  its  high  position  in  the 
pelvis,  an  assistant  may  be  able,  by  well  regulated  but  firm  suprapubic 
pressure,  to  bring  it  within  reach  of  the  palpating  finger;  or  it  may  be 
gently  drawn  down  by  the  aid  of  the  catheter  within  the  bladder. 

Such  an  examination  as  this  will  usually  enable  us  to  say  whether 
or  not  the  prostate  is  enlarged.  The  surgeon  should  remember,  how- 
ever, that  many  symptoms  of  enlargement  of  the  prostate  may  exist 
without  any  enlargement  being  present;  and  that  enlargement  of  the 
prostate  may  exist  and  yet  give  rise  to  no  symptoms;  and,  further- 
more, that  even  where  characteristic  symptoms  and  prostatic  enlarge- 
ment are  both  found,  one  is  not  necessarily  caused  by  the  other. 
Hence  no  surgeon  should  undertake  any  plan  of  treatment  hastily,  or 
without  due  consideration  in  cases  of  this  kind.  Indeed,  it  is  often 
best  to  temporize  for  awhile,  until  by  making  repeated  and  careful 
examinations  all  possible  sources  of  error  have  been  eliminated,  and 
the  condition  of  the  parts  involved  has  become  familiar  to  the  surgeon. 

In  the  local  examination  such  as  has  been  described,  it  has  been 
assumed  that  the  urethra  was  freely  open  to  instrumentation;  but  in 
very  many  patients  this  is  not  the  case:  strictures,  false  passages,  and 
obstruction  by  the  prostate  itself  may  render  such  an  examination 
impossible;  and  hence  oftentimes  the  best  that  can  be  done  is  to 
improve  the  condition  of  the  urethra,  and  so  persist  until  a  satisfactory 
examination  finally  becomes  possible.  Enlargement  of  the  prostate 
is  not  a  disease  in  which  haste  is  advisable.  Most  of  the  foregoing 
procedures  have  today  been  discarded  in  favor  of  the  cystoscope,  the 
use  of  which  in  cases  of  prostatic  hypertrophy  is  described  elsewhere. 
There  are,  however,  cases  in  which  cystoscopic  examination  is 
impossible  or  impracticable  and  in  this  group  recourse  may  well  be 
had  to  the  measures  described  above. 

Besides  the  condition  of  the  urinary  tract,  the  surgeon  should 
always  make  a  thorough  general  physical  examination.  The  signs  of 
age,  whether  premature  or  not,  should  be  sought  for:  the  condition 
of  the  arteries,  the  arcus  senilis,  the  cardiac  action,  and  the  general 
circulation  all  require  attention.  The  general  health  should  be  de- 
termined— the  appetite,  the  habits  as  to  smoking  and  drinking,  the 
digestion,  the  amount  of  sleep  usually  obtained,  and  the  ability  to 


Cardiac  Symptoms  135 

pursue  the  usual  occupation — none  of  these  should  be  neglected.  The 
state  of  the  heart  and  the  kidneys  is  of  the  utmost  importance:  in- 
creased renal  pressure  and  the  consequent  toxemia  soon  make  their 
presence  known  by  cardiac  hypertrophy,  with  increase  in  size  of  the 
left  ventricle,  evidenced  by  displacement  of  the  apex-beat  downwards 
and  to  the  left,  and  by  the  stronger  and  longer  first  cardiac  sound  in 
the  same  situation,  with  the  well-known  accentuated  second  aortic 
sound;  so  that  any  surgeon  who  pretends  to  accuracy  in  diagnosis  would 
be  guilty  of  great  oversight  if  he  neglected  a  careful  examination  of  the 
heart.  Of  even  greater  importance  than  the  detection  of  cardiac 
hypertrophy,  is  it  to  discover  the  early  signs  of  dilatation  of  the  heart. 
It  is  probable  that  the  accentuation  of  the  second  aortic  sound,  above 
referred  to,  is  not  an  early  sign  of  hypertrophy,  so  that  where  it  has 
existed  for  some  time,  the  evidences  of  dilatation  may  be  shortly 
expected;  here  the  weakening  of  the  first  apical  sound,  with  the 
production  of  a  mitral  systolic  murmur,  and  increase  of  cardiac  area 
to  the  right  of  the  sternum,  with  perhaps  occasional  murmurs  of  in- 
competency over  the  aortic  valves,  we  regard  as  the  most  valuable 
local  signs.  But  as  further  evidence  of  cardiac  dilatation  we  would 
call  special  attention  to  the  various  results  of  venous  congestion,  such 
as  dyspnoea,  oedema  of  the  extremities,  varicose  veins,  hemorrhoids, 
hepatic  and  gastric  congestion,  loss  of  appetite,  and  flatulency  with 
indigestion. 

The  functional  capacity  of  the  kidneys  must  be  ascertained  before 
any  operation  is  attempted  for  the  relief  of  chronic  urinary  obstruction. 
The  various  tests  employed  in  this  determination  are  described  in  the 
chapter  devoted  to  diagnosis. 

An  examination  of  the  blood  will  be  of  interest;  though  it  cannot  be 
expected  to  aid  in  the  diagnosis.  The  percentage  of  hemoglobin  is 
the  most  important  point  to  be  determined,  since  by  it  we  gain  a  fairly 
accurate  index  of  the  patient's  ability  to  withstand  operative  treatment. 
The  coagulation  time  of  the  blood  should  be  determined  for  obvious 
reasons. 

REFERENCES  (CHAPTER  VII) 

Moullin:  Enlargement  of  the  Prostate,  London,  1899,  2d  ed.;  1904,  3d  ed. 
Paget:  Lectures  on  Surgical  Pathology,  London,  1870,  3d  ed.,  p.  380. 


CHAPTER  VIII 

DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS;  CYSTOSCOPIC 
DIAGNOSIS;  KIDNEY  FUNCTIONAL  TESTS 

The  diagnosis  of  prostatic  enlargement  is  usually  not  difficult. 
In  the  first  place,  the  clinical  history,  or  the  sequence  of  symptoms,  is 
almost  invariably  characteristic.  Increased  frequency  of  urination,  in 
a  patient  past  the  prime  of  life,  will  at  once  direct  our  attention  to 
the  prostate.  Retention  may  have  necessitated  the  passage  of  a  cath- 
eter once  or  oftener.  If  the  retention  has  been  due  to  strictures,  the 
patient  will  usually  be  quite  well  aware  of  the  fact,  and  will  be  more 
inclined  to  confess  their  presence  than  perhaps  a  younger  man  who  may 
have  the  memory  of  their  onset  and  early  stages  more  vividly  in  his 
mind,  and  may  regard  them  as  more  of  a  reproach. 

Many  of  these  patients  will  have  been  under  treatment  by  another 
practitioner,  and  will  know  their  own  malady  well,  so  that  frequently 
the  surgeon  has  only  to  confirm  a  diagnosis  already  made.  But  it  is 
well  not  to  forget  that  the  physician,  no  matter  how  high  his  reputa- 
tion, may  have  erred  in  his  diagnosis,  and  that  therefore  in  enlarged 
prostate  as  in  other  affections  it  is  safe  not  to  take  a  ready-made 
diagnosis. 

As  a  rule,  the  age  of  the  patient  and  his  nocturnal  frequency  of 
urination  are  sufficient  to  arouse  suspicion.  As  has  been  already  men- 
tioned, the  general  aspect  of  the  patient,  together  with  a  urinous  odor, 
due  to  overflow  from  retention  causing  his  clothing  to  be  more  or  less 
constantly  wet,  will  in  some  instances  enable  the  acute  observer  to 
anticipate  the  diagnosis  even  before  the  patient  states  his  troubles. 
Even  in  cases  seemingly  obscure  at  first,  a  detailed  history  of  the  case 
and  a  complete  and  strictly  systematic  physical  examination  will 
invariably  enable  a  correct  diagnosis  to  be  made.  It  is  only  where  small 
or  impassable  strictures  prevent  instrumental  examination  of  the  vesical 
surface  of  the  prostate  that  a  diagnosis  becomes  at  times  impossible, 
unless  sufficient  enlargement  can  be  felt  by  the  rectum  to  render  an 
intravesical  examination  superfluous. 

The  stage  of  the  disease  is  usually  more  easily  determined  from  the 
symptoms  than  from  the  physical  examination.     The  most  important 

136 


Clinical  Picture  137 

change  in  the  life-history  of  these  patients  is  that  produced  by  cystitis, 
which  unfortunately  is  nearly  certain  to  make  its  appearance  sooner 
or  later.  Naturally,  the  earHer  the  stage  at  which  prostatics  are  first 
seen,  the  greater  is  the  hope  of  cure.  When  the  urine  is  constantly  of  a 
specific  gravity  below  i.oio,  the  action  of  the  kidneys  is  manifestly  im- 
paired, and  the  disease  may  be  considered  quite  far  advanced.  The 
symptomatology  of  prostatic  disease  is  dependant  upon  the  size  of  the 
prostate,  the  degree  of  obstruction  to  the  urethra  to  which  it  has  given 
rise,  and  to  complications,  of  which  the  most  important  are  cystitis, 
vesical  calculus,  and  infections  of  the  kidney  and  the  renal  pelvis.  But 
from  the  operative  standpoint,  and  indeed  from  the  standpoint  of  prog- 
nosis, the  symptoms  are  of  comparatively  little  importance.  Thus  a 
patient  who  is  suffering  very  slightly  may  prove  to  be  a  very  poor 
operative  risk  on  account  of  grave  disturbances  of  renal  function.  The 
diagnosis  of  prostatic  obstruction  entails  therefore,  not  only  the  deter- 
mination of  the  presence  of  an  enlarged  prostate  gland,  but  of  the  local 
and  systemic  comphcations  as  well.  In  this  chapter  we  will  describe 
the  clinical,  instrumental,  and  laboratory  means  of  diagnosing  prostatic 
enlargement  and  of  differentiating  it  from  those  conditions  which  may 
give  rise  at  times,  to  similar  symptoms.  The  longer  infection  is  absent, 
the  longer  is  the  disease  apt  to  endure  in  a  quiescent  state,  the  patient 
being  troubled  mainly  with  frequency  of  urination  until  the  accumula- 
tion of  residual  urine  produces  overflow. 

The  cardinal  principle  by  which  we  determine  the  size  of  any  body  is 
by  learning  the  distance  between  its  surfaces,  or  its  diameter;  to  accom- 
plish this  in  the  case  of  an  organ  situated  as  is  the  prostate,  it  is  absolutely 
essential  to  gain  entrance  to  the  bladder  above  and  to  the  rectum 
below.  It  is  not  sufficient  merely  to  insert  a  finger  into  the  rectum 
and  to  palpate  the  prostate;  nor  is  it  enough  to  learn  by  catheterization 
that  the  urinary  distance  is  increased,  that  the  subpubic  urethra  devi- 
ates from  the  normal  curve,  and  that  there  is  residual  urine.  By  the 
rectal  touch  frequently  no  enlargement  can  be  detected  while  decided 
urinary  obstruction  exists  from  overgrowth  into  the  bladder  or  the 
urethra;  and  the  information  gained  from  the  passage  of  a  catheter 
alone  is  manifestly  incomplete.  Hence  before  making  a  positive  diag- 
nosis the  surgeon  should  resort  to  the  combined  examination  with  a 
sound  or  catheter  within  the  bladder,  and  a  finger  in  the  rectum,  and 
with  few  exceptions  to  cystoscopic  examinations. 

But  merely  to  ascertain  that  the  bulk  of  the  prostate  gland  is 
increased  is  not  to  make  sure  the  diagnosis  of  "enlargement  of  the 


138  Diagnosis 

prostate."  Enlargement  may  exist  from  various  morbid  processes, 
such  as  chronic  prostatitis,  prostatic  abscess,  calculus,  or  tumors  of  the 
prostate;  and  it  is  chiefly  by  attention  to  the  clinical  history  of  the  case 
that  a  distinction  between  these  different  forms  of  enlargement  is 
reached,  although,  as  will  be  mentioned  under  the  head  of  differential 
diagnosis,  the  sense  of  touch  will  aid  us  here  as  well. 

It  is  an  important  thing  to  be  able  to  distinguish  between  the  two 
main  classes  of  prostatic  overgrowth^ — the  glandular  and  the  fibrous — 
since  the  same  operation,  if  one  is  indicated,  is  not  usually  advisable 
for  both  varieties. 

The  prostate  which  has  undergone  a  change  which  is  chiefly  adeno- 
matous in  character  is  larger  and  less  dense  than  the  normal  organ,  and 
is  usually  not  firmly  fixed,  unless  its  great  size  makes  it  so;  the  rectal 
mucous  membrane  glides  easily  over  its  surface;  the  general  outline  of 
the  two  lobes  and  the  intervening  commissure  can  often  be  distin- 
guished; and  well-defined  adenomatous  masses  (prostatic  tumors)  of 
greater  than  the  normal  density  may  at  times  be  palpable  in  the  sub- 
stance of  the  gland;  while  the  surface  may  present  similar  protuber- 
ances, sessile  or  pedunculated. 

The  bladder  in  such  cases  is  more  apt  to  be  dilated  than  contracted; 
cystitis  is  either  slight  or  absent;  and  the  patient  may  reach  the  stage 
of  retention  with  overflow  before  he  has  observed  any  marked  devia- 
tion from  his  usual  health.  The  duration  of  the  malady  and  of  the 
urinary  frequency  will  usually  have  been  several  years  at  the  least. 

Where  the  fibrous  prostate  has  developed,  the  organ  will  be 
but  slightly  enlarged,  or  may  in  rare  instances  even  become  smaller 
than  the  normal.  Its  density  is  increased;  periprostatitis,  as  a  rule, 
has  occurred,  causing  the  formation  of  fibrous  tissue  about  the  prostate, 
so  that  it  is  less  movable  than  normal;  the  rectal  mucous  membrane 
will  be  less  able  to  glide  over  the  surface  of  the  altered  gland;  and  the 
outlines  of  the  prostate  will  be  more  difl5cult  to  determine.  No 
protuberances  are,  as  a  rule,  to  be  felt  on  its  surface,  and  so  dense 
is  its  whole  substance  that  embedded  tumors,  if  present,  cannot  be 
detected. 

The  bladder,  in  the  case  of  the  fibrous  prostate,  has  probably  early 
been  exposed  to  infection:  it  is  found  contracted,  its  walls  thickened, 
and  its  surface  perhaps  pouched.  As  a  consequence,  distressing  symp- 
toms have  made  themselves  prominent  early  in  the  case;  and  the 
patient  may  give  a  history  of  only  a  few  months'  or  a  year's  duration; 
while  he  rarely,  if  ever,  reaches  the  stage  of  overflow,  as  the  constantly 


Differential  Diagnosis  139 

recurring  desire  for  urination  has  impelled  him  to  keep  his  bladder  nearly 
empty,  by  catheterization  or  otherwise. 

It  is  the  contemplation  of  these  two  clinical  pictures — the  one  a 
dilated  and  passive  bladder,  the  other  a  contracted,  infected,  irritable 
bladder — that  makes  it  seem  improbable  that  the  two  forms  of 
prostatic  disease  are  due  to  the  same  causes:  inflammatory  action 
seems  so  pronounced  in  the  latter  class,  and  so  latent  in  the  former. 

Differential  Diagnosis. — Very  many  of  the  symptoms  and  of  the 
physical  signs,  as  well,  presented  by  prostatics,  are  known  to  occur 
in  other  affections.  Hence  it  frequently  becomes  necessary  for  the 
surgeon  to  consider  the  differential  diagnosis  of  these  cases,  and  at 
times  to  form  his  ideas  by  the  method  of  exclusion. 

Atony  of  the  bladder,  being  itself  often  caused  by  prostatic  ob- 
struction, may  first  claim  our  attention.  The  symptoms  of  this 
malady,  even  when  produced  by  another  cause,  may  very  closely 
simulate  those  attendant  upon  enlargement  of  the  prostate:  thus 
the  patient  will  find  himself  required  to  strain  immoderately  to  start 
the  flow  of  urine,  he  will  be  long  in  emptying  his  bladder,  and  may  be 
aware  that  some  portion  of  his  urine  constantly  remains  unevacuated. 
As  a  consequence  of  these  changes  the  frequency  of  urination  may  be 
increased,  and  it  may  become  impossible  to  differentiate  the  two  affec- 
tions from  the  symptoms  alone.  But  the  surgeon  will  very  easily  dis- 
tinguish mere  vesical  atony  from  the  train  of  symptoms  and  their 
complications  due  to  prostatic  enlargement  as  soon  as  he  seeks  a  cause 
for  the  symptoms.  The  history  of  the  patients  may  be  the  same,  but 
by  simply  passing  a  catheter,  and  palpating  the  prostate  at  the  same 
time  from  the  rectum,  enlargement  of  this  organ  can  be  readily  excluded. 

The  most  common  non-obstructive  causes  of  atony  of  the  bladder 
are  diseases  of  the  central  nervous  system,  of  which  tabes  and  cerebro- 
spinal lues  are  the  most  important.  Lateral  and  multiple  sclerosis  are 
sometimes  productive  of  urinary  retention  and  atony  of  the  bladder. 
If  we  assume  that  all  causes  of  urinary  retention  give  rise  secondarily 
to  atony  of  the  bladder  walls,  a  large  number  of  factors  must  be  given 
etiological  influence.  Habitual  retention  continued  for  many  years 
will  cause  weakening  of  the  vesical  musculature  which,  with  prostatic 
hypertrophy  coming  on  in  later  years,  becomes  much  exaggerated. 
Retention  of  cerebral  or  spinal  origin  may  be  partial  or  complete,  and 
not  infrequently  is  followed  by  incontinence  of  urine  when  the  sphinc- 
teric  system  becomes  partially  or  completely  paralysed.  The  prostate 
gland  is  generally  atrophied  in  the  presence  of  a  spinal  lesion,  but  in 


140  Diagnosis 

some  instances  a  true  hypertrophy  is  found.  The  symptoms  may  be 
characteristic  of  prostatism  even  to  the  overflow  of  retention,  but 
operation  must  not  be  considered  until  it  is  definitely  proved  that  the 
incontinence  is  not  due  to  the  spinal  lesion.  If  in  such  cases,  one  can 
be  quite  positive  that  the  cord  lesion  is  not  far  advanced  and  that  the 
atony  of  the  bladder  is  due  to  prostatic  obstruction  and  not  to  the 
spinal   disease,   removal  of  a  large  prostatic  growth  is  justifiable. 

Atony  sometimes  results  from  retention  due  to  hysteria  or  other 
psychic  causes  but  this  is  easily  differentiated  from  obstructive 
atony.  Retention  due  to  reflex,  toxic,  and  infectious  causes  gives 
rise  to  very  slight  degrees  of  atony.  In  a  small  number  of  patients  the 
most  characteristic  symptoms  of  obstruction  at  the  vesical  neck  exist, 
but  in  which  no  obstructive  cause  for  the  retention  and  atony  can  be 
found.  Swinburne  attributes  the  retention  in  these  cases  to  a  reflex 
from  lesions  of  the  rectum  or  the  deep  urethra. 

The  differential  diagnosis  between  atony  due  to  enlargement  of 
the  prostate  and  those  cases  due  to  the  other  causes  just  enumerated 
is  usually  made  by  cystoscopic  examination.  In  marked  states  of 
atony  secondary  to  prostatic  hypertrophy  the  removal  of  the  prostate 
may  be  followed  by  temporary,  and  usually  partial  incontinence.  In 
quite  a  number  of  cases  in  which  marked  over-distention  of  the  bladder 
exists  before  operation  the  removal  of  the  prostate  does  not  completely 
restore  the  tone  of  the  vesical  musculature,  and  small  amounts  of  resi- 
dualurine  may  be  demonstrated  to  exist  in  these  cases.  The  func- 
tional results  however  are  satisfactory.  Atony  of  the  bladder  dependent 
solely  upon  prostatic  enlargement  need  cause  no  apprehension  if  the 
obstruction  is  completely  removed  at  operation. 

Where  strictures  of  the  urethra  are  present,  the  exclusion  of  pros- 
tatic hypertrophy  is  more  difficult.  Although  the  age  of  the  patient 
may  render  the  presence  of  the  latter  affection  extremely  improbable, 
yet  many  of  the  symptoms  are  the  same — slow,  difficult  urination, 
with  atony  of  the  bladder,  as  well  as,  possibly,  hemorrhoids  and  pro- 
lapsus ani.  But  the  passage  of  an  instrument  of  full  size  into  the 
urethra  will  show  obstruction  more  or  less  complete  to  exist  within 
eighteen  centimetres  of  the  meatus;  and  if  entrance  to  the  bladder  can 
be  gained,  the  absence  of  enlargement  of  the  prostate  is  readily 
determined  by  the  combined  rectal  and  vesical  examination  already 
described.  In  cases,  however,  of  impermeable  strictures  with  chronic 
retention,  it  will  not  be  possible  satisfactorily  to  examine  the  pros- 
tate until  these  conditions  are  relieved. 


Differential  Diagnosis  141 

Cystitis,  when  unaccompanied  by  stricture  or  prostatic  enlargement, 
is  unattended  by  residual  urine,  and  although  the  crebruria  may  simu- 
late that  of  overflow  from  retention,  this  affection  is  readily  proved  not 
to  exist  by  the  passage  of  a  catheter;  while  combined  intravesical  and 
rectal  examination  will  reveal  a  prostate  of  normal  size. 

Quite  a  number  of  patients  are  being  subjected  to  prostatectomy 
for  the  relief  of  urinary  incontinence  which  is  in  reality  caused  by 
tabetic  paralysis  of  the  bladder.  Needless  to  say  the  operation  not 
only  fails  of  its  purpose  but  aggravates  the  condition. 

Incontinence  of  urine  due  to  tabes  or  other  lesions  of  the  cord  co- 
exist with  true  hypertrophy  of  the  prostate  gland,  and  the  examiner 
given  to  superficiality  in  diagnosis  is  very  likely  falsely  to  accuse  the 
enlarged  prostate  and  advise  its  removal.  We  have  seen  a  number  of 
patients  who  had  previously  been  operated  upon  for  the  cure  of  an 
incomplete  incontinence  which  immediately  thereafter  became  complete. 
The  presence  of  tabes  should  be  suspected  in  an  individual  who  com- 
plains of  intermittent  incontinence,  especially  of  the  nocturnal  variety. 
An  important  concomitant  symptom  is  loss  of  sexual  power.  If  on 
further  examination  the  prostate  is  found  to  be  only  moderately  en- 
larged the  certainty  of  the  tabes  is  enhanced.  The  bladder  wall  of 
tabetics  like  that  of  prostatics  is  frequently  trabeculated,  but  little  is 
gained  by  cystoscopic  examination  to  aid  the  diagnosis  except  to  con- 
firm the  minor  degree  of  prostatic  enlargement.  Whenever  the  sus- 
picion of  tabes  exists,  the  patient  should  be  given  the  benefit  of  a 
complete  neurological  examination.  The  serological  study  of  the 
spinal  fluid  is  of  paramount  importance  in  the  differential  diagnosis  of 
doubtful  cases. 

Where  a  vesical  calculus  exists,  it  is  not  liable  to  be  mistaken  for 
an  enlarged  prostate  unless  it  is  both  firmly  fixed  in  the  neighborhood 
of  this  organ  and  so  thickly  coated  with  mucus  that  no  grating  sensation 
is  imparted  to  the  sound.  In  these  rare  circumstances  it  may  like- 
wise be  missed  during  the  cystoscopic  examination.  But  even  under 
such  circumstances  there  may  be  no  residual  urine,  which  is,  as  already 
insisted  upon,  a  nearly  invariable  accompaniment  of  every  enlarged 
prostate  producing  symptoms;  and  there  will  probably  not  be  the  char- 
acteristic change  in  the  curve  of  the  subpubic  urethra.  If  the  calculus 
is  prostatic,  or  even  if  it  merely  coexists  with  an  enlarged  prostate,  a 
positive  diagnosis  is  more  difficult.  Stones  of  considerable  size  may 
be  readily  overlooked  during  a  cystoscopic  examination  when  they  have 
become  coated  with  mucus  and  lie  in  a  deep  post-prostatic  pouch.     A 


142  Diagnosis 

diverticulum  containing  a  stone  may  give  rise  to  much  post-operative 
trouble  in  cases  in  which  neither  the  diverticulum  nor  the  stone  were 
diagnosed  before  operation.  In  about  one  out  of  four  patients,  it  is 
to  be  remembered,  a  calculus  complicates  the  enlarged  prostate; 
according  to  Freyer,  stone  complicates  prostatic  hypertrophy  in 
17.6  per  cent  of  cases.  Bleeding  is  more  common  in  cases  of  calculus 
than  in  those  of  enlarged  prostate  alone,  and  the  pain  is  less  constant, 
and  more  confined  to  times  when  the  bladder  contracts  upon  the  concre- 
tion, or  when  the  patient  is  actively  moving  about.  The  fact  must 
not  be  lost  sight  of  that  pain  due  to  stone  in  the  bladder  which  occurs 
in  connection  with  enlargement  of  the  prostate  is  felt  at  the  end  of 
micturition,  but  that  in  the  presence  of  residual  urine,  pain  may  be 
absent  as  the  bladder  walls  do  not  contract  in  every  instance  sufficiently 
to  cause  contact  with  the  stone.  The  pain  frequently  radiates  to  the 
end  of  the  penis.  In  uncomplicated  prostatic  enlargement  pain  is 
usually  an  insignificant  symptom.  In  calculus,  moreover,  the  greatest 
frequency  of  micturition  is  during  the  day,  and  the  patients  are  not 
apt  to  be  disturbed  much  at  night.  A  skiagraphic  examination  will 
at  times  detect  the  presence  of  a  calculus  when  other  means  have 
failed. 

Probably  the  most  diflicult  diagnosis  of  all  is  that  from  poly- 
poid growths  in  the  bladder,  which  when  springing  from  the  region 
of  the  prostate  may  very  closely  simulate  a  pedunculated  "middle 
lobe"  of  this  organ.  But  in  nearly  all  forms  of  vesical  tumor,  other 
than  prostatic,  spontaneous  hemorrhage  is  an  early  and  conspicuous 
symptom,  and  is  usually  not  attended  by  much  pain.  In  some 
cases,  moreover,  fragments  of  the  tumor  are  passed  in  the  urine,  so 
that  a  microscopic  examination  may  render  the  true  condition  of 
affairs  manifest.  A  polypoid  tumor  of  the  bladder  which  has  become 
encrusted  with  urinary  salts  may  present  a  cystoscopic  picture  very 
much  like  that  of  calculus.  The  tumor,  however,  is  fixed  and  careful 
scrutiny  of  its  basal  portion  will  very  likely  show  that  it  is  adherent  to, 
or  rather  springing  from,  the  bladder  wall.  In  contour  the  tumor  is 
usually  unhke  that  of  calculus,  and  some  area  of  the  growth  will  usu- 
ally have  escaped  encrustation  so  that  the  diagnosis  is  apparent. 
There  are,  however,  some  cases  in  which  an  encrusted  tumor  so  closely 
resembles  in  cystoscopic  appearance,  a  calculus  that  a  mistake  in  diag- 
nosis is  excusable. 

Tuberculosis  of  the  bladder  may  occasionally  simulate  enlarge- 
ment of  the  prostate  by  the  symptoms  it  produces.     But  it  probably 


Differential  Diagnosis  .  143 

always  coexists  with  similar  disease  elsewhere  in  the  body,  most  often 
in  the  kidney  or  epididymis.  Hence  in  doubtful  cases  this  should 
be  borne  in  mind,  and  the  spermatic  cords  and  seminal  vesicles  exam- 
ined as  well.  The  cystoscope  here  may  be  of  considerable  aid,  enabUng 
the  surgeon  to  localize  a  tuberculous  ulcer  in  the  bladder,  and  thus 
render  it  accessible  for  topical  treatment.  If  the  tuberculous  disease 
affects  the  prostate,  there  can  usually  be  detected  areas  of  soften- 
ing, in  the  irregularly  enlarged  organ;  and  although  it  might  at  times 
seem  difficult  to  distinguish  between  areas  of  softening  in  a  prostate 
somewhat  denser  than  normal  (tuberculous  disease),  and  areas  of 
hardening  in  a  rather  less  dense  organ  (adenomatous  enlargement 
with  prostatic  "tumors"),  yet  other  features  in  the  case  will  usually 
enable  the  diagnosis  to  be  made. 

Chronic  prostatitis  often  succeeds  upon  the  acute  form  of  the 
disease,  which  is  sufficiently  manifested  by  its  abrupt  onset,  positive 
inflammatory  character,  excessive  tenderness  on  rectal  exploration, 
and  by  its  occurrence,  generally  as  a  sequel  to  gonorrhoea,  in  a  younger 
patient. 

Abscess  of  the  prostate  likewise  usually  follows  acute  inflammation, 
but  may  be  traumatic  in  origin.  Besides  the  history  of  the  case,  the 
course  of  this  affection  is  so  acute  compared  to  that  of  enlargement  of 
the  prostate,  that  confusion  is  not  likely  to  arise.  Moreover,  the  ab- 
scess may  point  in  the  urethra,  the  rectum,  or  the  perineum;  and  palpa- 
tion may  enable  a  diagnosis  to  be  made  before  rupture  renders  it  certain. 

Chronic  prostatitis  unassociated  with  periprostatitis  rarely  gives 
rise  to  prostatism:  this  equally  applies  to  all  forms  of  the  disease 

By  far  the  greater  number  of  cases  of  chronic  prostatitis  are  non- 
obstructive in  nature  and  present  no  difficulties  in  differentiation  from 
the  adenomatous  form  of  prostatic  hypertrophy.  In  the  minority  of 
cases  chronic  prostatitis  is  merely  a  part  of  a  widespread  inflammatory 
process.  The  inflammation  begins  primarily  in  the  prostate  gland  but 
comes  eventually  to  involve  the  surrounding  structures  and  results  in 
the  deposition  of  scar  tissue.  The  normal  flexibility  of  the  parts  is 
then  destroyed  and  as  a  result  of  contracture  of  the  vesical  neck  the 
normal  bladder  function  is  interfered  with  and  prostatism  results. 

The  prostate  gland  itself  in  these  cases  is  usually  atrophied,  and  so 
dense  in  consistency  that  the  suspicion  of  carcinoma  is  aroused  by  digital 
examination  of  its  rectal  surface.  It  is,  however,  fixed  to  the  pelvic 
fascia  and  shows  no  tendency  to  spread  upward  between  the  vesicles 
beneath  the  trigonal  area  of  the  bladder,  as  is  characteristic  of  carcin- 


144  Diagnosis 

oma.  The  gland  is  small  and  irregular  in  outline  while  the  carcinoma- 
tous gland  is  rarely  atrophied,  and,  except  in  later  stages,  more  or  less 
regular  in  surface  outline,  with  one  or  more  areas  of  great  density.  To 
this  type  of  prostate  Chetwood  has  long  since  given  the  name  of  scler- 
osis of  the  neck  of  the  bladder;  a  name  descriptve  of  the  associated 
pathology  in  the  region  of  the  vesical  neck.  The  less  descriptive 
term  atrophy  of  the  prostate  is  employed  by  the  French  to  denote 
the  condition. 

In  a  certain  small  proportion  of  cases  an  associated  cystitis  leads  to 
concentric  hypertrophy  of  the  bladder  walls.  In  these  cases  the  bladder 
capacity  is  small,  and  this  factor  together  with  the  accompanying 
cystitis,  often  with  ulceration  of  the  mucosa,  and  the  obstruction  at  the 
vesical  neck,  renders  this  class  of  patients  the  most  miserable  of  sufferers. 
Notwithstanding  the  small  bladder  capacity  there  is  usually  a  small 
quantity  of  residual  urine  present,  a  quantity  small  in  amount  but 
relatively  great  for,  while  the  residual  may  measure  only  fifteen  c.c.  the 
total  capacity  of  the  viscus  may  be  only  sixty  c.c.  or  even  less.  The  ques- 
tion in  these  cases  is  not  one  of  diagnosis  alone;  more  important  is  the 
recognition  of  associated  changes  such  as  hydro-ureter,  diverticulae, 
and  stone. 

Contracture  of  the  vesical  neck  associated  with  the  ordinary  symp- 
toms of  prostatism  is  diagnosed  with  ease.  Rectal  examination  proves 
the  absence  of  large  extravesical  adenomatous  masses,  and  the  true 
pathology  of  the  disease  is  easily  demonstrable  cystoscopically.  The 
conditions  commonly  found  are  a  bar  at  the  vesical  outlet  or  contracture 
of  the  vesical  neck  caused  by  an  annular  deposit  of  scar  tissue. 

Malignant  disease  of  the  prostate  is  chiefly  of  the  adeno-carcino- 
matous  variety.  In  some  few  instances  the  tumor  cells  arrange 
themselves  in  irregular  nests  or  in  solid  strands  situated  in  the  midst  of 
a  more  or  less  dense  matrix.  These  latter  are  properly  grouped  as 
scirrhous  in  type.  The  rapidly  growing  medullary  carcinoma  rarely  if 
ever  occurs  in  the  prostate  gland.  One  of  the  chief  characteristics  of 
prostatic  carcinoma  is  its  tendency  to  comparatively  early  and  wide- 
spread metastases.  Practically  all  organs  are  subject  to  these  metas- 
tatic deposits  but  the  bones  are  particularly  liable.  In  some  instances 
the  osseous  system  and  the  pelvic  lymph  nodes  are  the  only  structures 
involved. 

A  very  small  nodule  of  prostatic  carcinoma  may,  like  a  similar 
nodule  in  the  breast,  give  rise  to  widely  disseminated  metastases 
very  early  in  its  course.     Among  the  autopsy  records  of  the  Lankenau 


Differential  Diagnosis  145 

Hospital  we  find  the  description  of  such  a  case.  The  patient  died  of 
shock  following  a  suprapubic  prostatectomy.  The  specimen  was 
found  to  contain  a  small  peripheral  nodule  of  cancer  which  had  given 
rise  to  widespread  metastatic  deposits  in  the  abdominal  and  thoracic 
viscera.  A  factor  of  some  clinical  importance  is  the  tendency  of 
prostatic  carcinoma  to  spread  to  the  medullary  cavities  of  the  long 
bones.  The  bone  marrow  is  destroyed  with  the  deposition  of  new 
bone.  The  latter  is  subject  to  early  necrosis.  Early  and  profound 
anemia  and  pathological  fracture  are  noteworthy  sequelae  of  the  con- 
dition.    These,  however,  are  scarcely  of  great  diagnostic  importance. 

It  is  of  great  importance,  however,  to  remember  that  carcinoma  of 
the  prostate  is  a  common  disease;  far  commoner  than  is  usually  be- 
lieved. And  not  only  is  it  commonly  met  with  clinically,  but  the  fre- 
quency with  which  it  is  found  in  operative  specimens  thought  to  be 
benign  is  remarkably  great.  In  our  series  there  were  7.42  per  cent, 
of  these  cases,  and  this  proportion  would  undoubtedly  have  been  greater 
had  the  specimen  in  every  instance  been  subjected  to  more  thorough 
study.  The  frequency  of  cancer  of  the  prostate  is  said  by  Young  to  be  in 
the  rate  one  to  five  (20  per  cent,  of  500  cases) ;  by  Walker,  16.5  per  cent. ; 
by  Wilson  and  McGrath,  15.5  per  cent,  of  461  cases;  by  Albarran 
and  Halle,  14  per  cent.,  and  by  Freyer  13.3  per  cent,  of  1276  cases. 

Autopsy  records  give  even  a  greater  proportion  of  cancer  cases, 
for  among  204  diseased  prostates  found  by  Kiimmel,  21  per  cent,  were 
carcinomatous,  while  Gebele  states  that  in  his  experience  38  per  cent,  of 
diseased  prostates  found  at  autopsy  are  carcinomatous. 

These  figures  should  impress  the  reader,  without  further  comment 
from  us,  of  the  importance  of  remembering  the  frequency  of  carcinoma 
when  called  upon  to  diagnose  the  nature  of  a  diseased  prostate. 

The  age-incidence  of  prostatic  carcinoma  gives  no  clue  to  the 
nature  of  the  disease  since  it  is  practically  the  same  as  that  of  benign 
hypertrophy.  It  occurs  perhaps  on  the  average  a  decade  later  than 
does  benign  hypertrophy,  but  to  this  rule  there  are  so  many  exceptions 
that  age  is  of  Kttle  diagnostic  importance. 

In  a  series  of  93  cases  reported  by  Judd,  the  age-incidence  is  tabu- 
lated as  follows : 

Number  between  50  and  60  years 21 

Number  between  60  and  70  years 34 

Number  between  70  and  80  years 3^ 

Number  between  80  and  90  years 2 

93 

10 


146  Diagnosis 

Wolff  has  reported  the  histories  of  six  patients  under  forty  years 
of  age;  one,  twenty-nine  years  of  age. 

The  symptomatology  of  early  cancer  of  the  prostate  is  almost 
identical  with  that  of  benign  hypertrophy,  with  which  indeed  it  is 
often  associated.  The  differential  diagnosis  between  these  conditions 
is  either  an  impossible  one  to  make,  or,  if  made  at  all  is  based  entirely 
on  the  physical  signs. 

There  is  however  one  exception  to  this,  namely,  pain  independent 
of  micturition  which  is  very  suggestive  of  malignancy.  At  first 
localized  to  the  region  of  the  prostate  and  constant,  it  later  becomes 
referred  especially  to  the  perineum,  the  back,  the  buttocks  and  the 
thighs. 

Referred  pain  is  a  late  symptom  of  prostatic  carcinoma.  It  is 
indicative  of  involvement  of  the  sheath  of  the  organ  in  the  vicinity  of 
which  the  large  nerve  trunks  are  situated. 

The  physical  findings  naturally  differ  with  the  state  of  the  progress 
of  the  disease.  It  should  not  be  forgotten  that  carcinoma  may  exist  in 
an  atrophied  prostate,  in  a  prostate  of  normal  size,  or  in  a  very  marked 
hypertrophied  gland.  The  size  of  the  organ  is  not  therefore  of  great 
importance  in  the  diagnosis.  In  the  absence  of  associated  pathology 
the  carcinomatous  prostate  is  generally  moderately  enlarged.  The 
contour  of  the  rectal  surface  of  the  carcinomatous  gland  is  irregular  or 
nodular  in  contrast  to  the  regular,  or  if  lobulated,  smooth  surface  of 
the  adenomatous  organ.  If  the  surface  of  a  carcinomatous  prostate  is 
sometimes  smooth  it  rarely  lacks  that  most  characteristic  of  all  physical 
findings,  namely,  increased  density.  In  some  instances  the  density 
of  an  old  fibroid  prostate  or  of  one  containing  a  calculus,  closely  simulates 
that  of  prostatic  carcinoma  and  the  differentiation  between  them  is 
extremely  difficult. 

The  small  dense  prostate,  an  end-result  of  an  ancient  chronic  in- 
flammation, is  universally  involved,  and  physical  examination  of  one 
part  of  the  organ  is  the  counter-part  of  every  other  portion  of  the 
gland.  This  is  rarely  true  of  the  carcinomatous  organ  in  which,  in  one 
or  more  parts,  the  stony  induration  of  the  carcinomatous  areas  will 
stand  out  in  sharp  contrast  with  the  softer  non-involved  areas.  The 
more  advanced  cases  will  scarcely  be  mistaken  for  chronic  prostatitis. 
When  the  malignancy  has  broken  through  the  sheath  and  extended 
upward  beneath  the  trigonum  of  the  bladder,  with  involvement  of 
one  or  both  vesicles,  and  possibly  an  ureter,  the  diagnosis  presents  no 
difficulties. 


Diflferential  Diagnosis  147 

Areas  of  stony  hardness  are  then  the  most  important  physical 
findings  in  carcinoma  of  the  prostate  gland.  They  may  occur  in  one  or 
both  lobes  and  in  some  instances  the  carcinoma  is  confined  to  a  single 
area  in  one  lobe.  The  examiner  must  bear  in  mind  that  the  big,  soft 
adenomatous  prostate  which  presents  itself  so  obtrusively  to  the 
examining  finger  may  contain  an  area  of  malignancy.  In  every  case 
therefore  a  most  painstaking  and  thorough  examination  of  the  entire 
rectal  surface  of  the  gland  should  be  made.  Judd  reports  that  75  per 
cent,  of  the  carcinoma  cases  operated  upon  in  the  Mayo  CHnic  are 
associated  with  benign  hypertrophy. 

We  will  reserve  for  separate  consideration  the  diagnostic  data  to  be 
obtained  in  these  cases  by  the  aid  of  the  cystoscope. 

Sarcoma  of  the  prostate  gland  is  an  exceedingly  rare  disease.  In 
the  few  cases  that  have  come  to  our  notice  the  diagnosis  could  scarcely 
have  been  mistaken  since  the  pelvis  was  almost  filled  with  a  rapidly 
growing  tumor  of  prostatic  origin. 

Powers,  who  has  collected  a  series  of  thirty-one  cases  from  the 
literature,  states  that  "the  diagnosis  is  at  times  easy,  at  times  difficult. " 
To  quote  this  writer  further  "a  rapidly  growing  tumor  of  the  prostate 
in  a  child  or  youth  is  probably  a  sarcoma.  So,  as  well,  is  a  rapidly 
growing,  soft,  balloon-like  prostatic  tumor  in  an  adult.  Pain  is  gener- 
ally marked,  and  is  referred  to  the  pubes,  perineum,  and  rectum. "  Of 
the  thirty-one  cases,  fifteen  occurred  in  children  less  than  eight  years  of 
age,  eight  between  the  ages  of  fifteen  and  twenty -five,  and  six  between 
the  age  of  fifty  and  seventy. 

Sarcoma  is  not  likely  to  be  mistaken  for  benign  hypertrophy,  but  if 
any  doubt  exists  a  brief  space  of  time  will  settle  the  question,  as  sarcoma 
invariably  grows  with  marked  rapidity. 

Sarcoma  of  the  prostate  gland  occurs  more  often  in  the  young  than  in 
the  aged  and  rarely  gives  rise  to  symptoms  of  urinary  obstruction  until 
late  in  its  course.  As  an  indication  of  its  rarity  may  be  mentioned  the 
fact  that  Proust  and  Vion  were  able  to  collect  only  thirty-four  cases  in 
1907.  To  these  Young  adds  a  case  and  upon  this  series  of  thirty-five 
cases  bases  the  statistics  for  an  excellent  chapter  which  he  has  con- 
tributed on  the  subject  in  Cabot's  Modern  Urology,  Vol.  I.  Of  these 
thirty-five  cases  only  eight  occurred  between  the  ages  of  fifty  and  eighty 
years. 

The  differentiation  between  benign  prostatic  hypertrophy  and  sar- 
coma of  the  prostate  is  not  often  difficult.  The  sarcomatous  prostate 
grows  with  a  rapidity  that  is  unknown  in  the  benign  disease,  notwith- 


148  Diagnosis 

standing  which  it  gives  rise  to  the  symptoms  of  prostatism,  either  late 
in  its  course,  or  not  at  all. 

By  the  time  the  patient  is  prompted  to  seek  advice  because  of  dy- 
suria  the  tumor,  will  have  reached  a  considerable  size,  sometimes  al- 
most filling  the  pelvis. 

The  tumor  is  usually  oval  in  form,  smooth  in  outHne  and  soft, 
almost  fluctuating  in  consistency.  It  may  however  be  lobulated  and 
irregularly  indurated. 

Sarcoma  usually  springs  from  the  upper  part  of  the  prostate  and 
shows  little  or  no  tendency  to  invade  the  bladder,  after  the  manner  of  a 
benign  enlargement.  It  pushes  the  bladder  upward  and  forward  and 
in  this  way  impairs  its  function.  But  this  is  late  in  occurrence.  Inva- 
sion of  the  urethra  takes  place  in  some  cases.  Metastases  occur  early 
and  the  tumor  spreads  rapidly  and  widely  among  the  pelvic  contents. 

The  tumor  grows  more  slowly  in  the  aged  than  in  the  young.  It 
is  likely  to  be  mistaken  for  benign  hypertrophy,  carcinoma,  or  abscess, 
depending  upoii  the  physical  characteristics  of  the  mass.  A  large  soft, 
almost  fluctuant  mass  suggests  abscess  to  the  examining  finger,  but  the 
systemic  symptoms  are  wanting  and  the  sarcomatous  mass  is  rarely 
very  tender. 

The  smaller  and  irregularly  indurated  sarcoma  of  the  prostate 
somewhat  resembles  benign  hypertrophy  but  with  this  important 
distinguishing  difference,  that  the  sarcoma  grows  with  greater  rapidity, 
and  since  it  usually  springs  from  the  upper  portion  of  the  prostate  is 
situated  at  a  higher  level  and  obliterates  the  normal  line  of  demarcation 
between  the  upper  edge  of  the  gland  and  the  bladder,  which  is 
almost  without  exception  demonstrable  in  cases  of  benign  hypertrophy. 

Pain  is  commonly  associated  with  prostatic  sarcomata. 

Carcinoma  will  not  be  confounded  with  sarcoma  if  one  remembers 
that  the  development  of  carcinoma  proceeds  slowly  with  upward 
extension  along  the  intervesicular  area  and  the  production  of  a  broad 
flat  placque  of  irregularly  indurated  tissue. 

The  marked  induration  so  characteristic  of  carcinoma  is  wanting 
in  sarcoma.  Hematuria,  a  late  symptom  in  carcinoma,  is  rarely  asso- 
ciated with  sarcoma. 

The  cystoscope  will  be  of  value  in  the  diagnosis  of  sarcoma  only  in 
demonstrating  the  presence  of  an  extravesical  mass  with  elevation  and 
distortion  of  the  trigonal  area  of  the  bladder. 

The  Cystoscopic  Diagnosis  of  Prostatic  Hypertrophy. — The 
diagnosis  of  prostatic  hypertrophy  cannot  be  said  to  be  complete 


Cystoscopy  149 

without  a  cystoscopic  examination.  True,  the  presence  of  a  large 
hypertrophied  prostate  may  be  determined  by  rectal  examination,  and 
much  may  be  learned  by  instrumental  exploration  of  the  urethra  and 
the  bladder.  But  a  thorough  study  of  the  intravesical  portion  of  the 
enlarged  prostate,  and  of  the  vesical  complications  that  are  associated 
with  it,  must  be  made  cystoscopically. 

Cystoscopy  in  the  aged  is,  however,  not  without  danger  and  it  is 
not  a  procedure  that  should  be  used  routinely.  Almost  every  patient 
with  an  enlarged  prostate  can  be  cystoscoped  safely  at  some  time 
during  the  course  of  his  pre-operative  treatment.  Before  the  exami- 
nation is  attempted,  the  general  health  of  the  patient  must  be  such  that 
he  will  react  promptly  to  the  not  inconsiderable  trauma  attendant 
upon  it.  So  far  as  the  urological  contra-indications  are  concerned, 
marked  renal  insufficiency  is  by  far  the  most  important.  An  exami- 
nation undertaken  under  these  circumstances  may  precipitate  an 
impending  uremia  which  not  infrequently  proves  fatal.  If  patients 
belonging  to  this  group  are  given  the  necessary  preliminary  treatment, 
the  renal  function  will  be  restored  little  by  little  and  the  time  will 
arrive  when  cystoscopy  and  later  prostatectomy  can  be  done  with  com- 
parative safety. 

Cystoscopy  is  especially  dangerous  in  that  group  of  cases  in  which 
the  amount  of  residual  urine  is  great,  the  kidney  function  markedly 
impaired,  and  in  which  the  bladder  has  never  been  instrumented. 
Patients  who  have  led  catheter  lives  for  a  considerable  period  of  time 
and  whose  kidneys  have  been  thus  decompressed,  as  indicated  by  a 
good  functional  capacity,  may  be  cystoscoped  with  safety.  Patients 
in  the  early  stages  of  prostatic  hypertrophy  with  small  amounts  of 
residual  urine  and  good  kidney  function  may  be  cystoscoped  at  once. 
No  patient  with  the  history  of  a  recent  attack  of  acute  urinary 
retention  should  be  cystoscoped  until  the  state  of  his  renal  function 
is  determined. 

Profuse  hematuria  is  a  contra-indication  to  immediate  cystoscopy. 
With  proper  treatment,  the  bleeding,  especially  if  it  comes  from 
prostatic  varices,  will  subside,  whereupon  the  examination  can  be 
made  more  safely  and  more  satisfactorily.  The  same  rule  appUes  to 
cases  complicated  by  severe  acute  cystitis. 

Patients  who  show  a  tendency  to  urethral  fever  after  the  passage 
of  a  catheter  should  not  be  cystoscoped;  it  is  safe  in  these  cases,  if  the 
diagnosis  of  prostatic  hypertrophy  is  clinically  justifiable,  to  proceed 
at  once  with  a  preHminary  cystostomy. 


150  Diagnosis 

If  it  is  found  that  the  introduction  of  the  instrument  is  attended 
with  unusual  difficulties  the  operator  must  not  persist  in  his  efforts. 
Such  difficulties  arise  from  stricture  of  the  urethra,  both  organic  and 
spasmodic  in  type;  from  marked  distortion  of  the  prostatic  urethra 
caused  by  bizarre  forms  of  the  invading  prostatic  tumor;  from  unusu- 
ally large  tumors  with  great  intravesical  projections,  and  from  unusual 
sensitiveness  of  the  urethra  and  the  vesical  neck.  Nothing  can  be  gained 
from  a  cystoscopic  examination  that  would  warrant  the  infliction  of 
long  and  great  suffering  on  an  old  man  with  an  enlarged  prostate.  In 
the  hands  of  a  skilful  cystoscopist,  and  no  cystoscopist  is  skilful  who 
lacks  gentleness  in  his  methods,  the  great  majority  of  prostatics  can 
be  examined  safely  but  the  time  for  such  examination  should  be 
selected  by  the  individual  who  is  directing  the  course  of  pre-operative 
treatment. 

Technique. — The  details  in  the  technique  of  cystoscopy  will  be  omit- 
ted except  in  so  far  as  they  pertain  to  the  examination  of  prostatic  cases. 
We  prefer  for  these  studies  a  simple  examining  instrument  with  an 
irrigating  attachment;  one  that  permits  of  water  distention  of  the 
posterior  urethra  which  can  thus  be  examined  together  with  the 
bladder,  and  a  good  picture  obtained  of  the  vesical  outlet.  Ureteral 
catheterization  is  rarely  necessary  in  prostatic  cases,  and  with  the 
elimination  of  the  catheter  channels  a  smaller  instrument  can  be 
employed  without  sacrificing  the  dimensions  of  the  field.  Some 
prefer  an  indirect  instrument  after  the  original  Nitze  pattern  in 
which  the  image  is  inverted,  and  claim  to  get  a  better  view  especially 
of  the  posterior  margin  of  the  vesical  outlet  with  this  instrument. 
Others  employ  a  direct  cysto-urethroscope  for  the  examination  of  the 
proximal  urethra.  Personally  we  prefer  to  use  a  corrected  image 
indirect  cystoscope  and  have  found  the  greatest  satisfaction  with  the 
cysto-urethroscopes  of  American  manufacture. 

Having  determined  the  fitness  of  the  patient  for  cystoscopic  exami- 
nation he  is  given  a  hypodermic  injection  of  morphine.  One-half  hour 
later  he  is  placed  on  a  suitable  cystoscopic  table,  or,  in  the  absence  of 
this,  on  a  flat  examining  table  with  the  legs  hanging  over  the  edge  of 
the  table  and  the  feet  resting  on  chairs;  in  the  absence  of  appropriate 
leg  rests  we  do  not  use  the  ordinary  lithotomy  stirrups,  but  prefer  the 
position  described  above. 

After  the  necessary  preparation,  which  includes  irrigation  of  the 
anterior  urethra  with  warm  boric  solution,  a  small  tablet  of  apothesine 
or  procain  is  placed  within  the  lips  of  the  meatus.     After  the  lapse  of  a 


Cystoscopy  151 

few  minutes  the  remaining  portions  of  the  urethra  are  anesthetized. 
For  this  purpose  we  employ  a  two  per  cent,  solution  of  procain.  The 
solution  may  be  introduced  into  the  urethra  through  a  small  French 
catheter  or  other  suitable  instrument.  We  usually  employ  a  metal 
syringe  the  barrel  of  which  has  a  capacity  of  30  cc. ;  the  cannula,  which 
has  a  screw  attachment  to  the  barrel,  should  have  a  calibre  of  at  least 
22°F.     This  is  simply  a  Keyes-Ultzmann  syringe  of  large  size. 

The  cannula  is  introduced  into  the  urethra  as  far  as  the  bulbous 
portion  at  which  point  a  small  quantity  of  the  anesthetic  solution  is 
ejected  from  the  syringe.  This  serves  to  remove  the  tendency  to 
spasm  on  the  part  of  the  compressor  urethra  and  the  external  vesical 
sphincter  muscles.  After  waiting  a  few  minutes  the  tip  of  the  cannula 
is  introduced  into  the  prostatic  urethra  into  which  the  remaining  portion 
of  the  anesthetic  is  introduced.  The  instrument  is  then  withdrawn 
and  after  a  few  minutes  the  cystoscope  may  be  easily,  and  usually, 
painlessly  introduced.  If  the  patient  has  recently  emptied  the  bladder 
the  amount  of  residual  urine  may  now  be  determined,  although  this  will 
probably  have  been  estimated  previously.  The  next  step  in  the  pro- 
cedure is  to  obtain  a  clear  medium  through  which  the  interior  of  the 
bladder  may  be  examined.  This  often  necessitates  repeated  washings 
to  remove  pus  and  blood.  If  the  bleeding  is  excessive,  adrenalin 
chloride  is  added  to  the  irrigating  fluid  and  only  small  quantities  of  the 
latter  are  introduced  into  the  viscus  at  each  washing  since  the  bleeding 
will  be  encouraged  by  over-distention.  Normal  saline  solution,  boric 
acid  solution  or  a  one  to  ten  thousand  solution  of  oxycyanid  of  mercury 
is  used  for  irrigating  purposes.  These  solutions  should  be  tepid  but 
never  very  warm. 

Having  obtained  the  maximum  of  cleanliness  of  the  bladder  mucosa, 
and  a  corresponding  clarity  of  the  distending  medium,  about  200  to 
250  cc.  of  the  latter  are  introduced  and  the  examination  is  proceeded 
with.  In  most  cases  the  cystoscopic  examination  may  be  easily  and 
systematically  completed;  in  cases  with  small  contracted  and  highly 
intolerant  bladders  the  examination  may  be  exceedingly  difficult  and 
the  results  attained  most  unsatisfactory. 

Cystoscopy  in  prostatics  as  well  as  in  other  bladder  cases  is  an 
operation  that  should  be  conducted  systematically.  The  instrument  is 
first  turned  so  that  the  summit  of  the  viscus  is  within  range  of  vision, 
whereupon  it  is  introduced  into  the  bladder  as  far  as  possible  without 
doing  injury  to  the  wall  against  which  the  beak  presses.  In  the  large 
capacious  atonic  bladders  some  difficulty  may  be  experienced  in  ob- 


152 


Diagnosis 


Fig.  56. — Trabeculation 
AND  Diverticula  of  Bladder 
Wall.     (Knorr.) 


taining  sufficient  distention  to  efface  the  redundant  folds  of  mucosa,  or 
having  accomplished  this,  to  bring  the  remote  portions  of  the  bladder 
wall  within  the  range  of  cystoscopic  vision.  The  window  of  the  in- 
strument is  brought  near  to  the  mucous  membrane  by  depressing  the 
ocular  end  and  the  interior  of  the  highest  portion  of  the  bladder  is  then 
carefully  examined  as  the  instrument  is  slowly  withdrawn.  When  the 
window  approaches  the  urethra  a  curtain-like  structure  will  be  seen 
which  obscures  the  upper  part  of  the  field,  and  below  and  behind  this 

the  bladder  cavity  appears  as  a  shadowed 
space.  This  curtain  is  the  sphincteric 
margin,  and  represents  the  dividing  line 
between  the  bladder  and  the  prostatic 
urethra.  The  instrument  is  again  pushed 
into  the  bladder  cavity  as  far  as  possible 
and  another  portion  of  the  mucosa  is 
examined  adjacent  to  that  at  the  summit 
of  the  viscus.  This  procedure  is  repeated 
until  all  of  the  interior  of  the  bladder  is 
examined  except  its  basal  portion,  or  in 
other  words,  until  the  summit  and  the 
lateral  walls  have  been  examined.  Compared  with  the  face  of  the 
clock  this  portion  is  represented  by  the  part  between  eight  o'clock  and 
four  o'clock. 

The  next  step  in  the  examination  is  the  observation  of  the  sphinc- 
teric margin.  Under  normal  circumstances  this  is  a  rounded  regularly 
concave  structure  in  its  upper  and  lateral  portions,  but  lacks  sharp 
definition  below  since  it  becomes  here  a  part  of  the  trigonum.  The 
normal  internal  vesical  sphincter,  as  viewed  cystoscopically,  resembles 
a  horseshoe  in  outline.  Distortions  of  the  outline  of  this  concave 
curtain  are  among  the  most  important  cystoscopic  findings  in  enlarge- 
ment of  the  prostate.  In  order  to  produce  these  irregularities  the 
enlarged  prostate  must  encroach  upon  the  sphincteric  area ;  there  must 
be  an  intravesical  projection  of  the  enlarged  organ.  In  some  cases, 
and  especially  in  early  ones,  the  growth  of  the  adenomatous  bodies  is 
for  the  most  part  into  the  urethra  under  which  circumstances  the  sphinc- 
teric outline  will  be  normal. 

Before  attempting  to  interpret  the  many  cystoscopic  pictures 
presented  at  the  vesical  outlet  of  prostatics,  one  must  first  understand 
the  anatomy  of  the  normal  outlet  and  famiharize  himself  with  the  gross 
pathology  of  the  enlarged  prostate.     He  will  then  have  no  difficulty  in 


Cystoscopy  153 

visualizing  the  various  intravesical  forms,  or  in  recognizing  them  when 
they  are  met  with  cystoscopically. 

In  many  instances  the  intravesical  portion  of  the  enlarged  prostate 
is  excessive  in  size  and  the  vesical  outlet  is  so  far  displaced  upward  and 
inward  that  it  becomes  a  difficult  matter  to  outline  the  orifice.  In  the 
majority  of  instances,  however,  the  characteristic  alteration  in  the 
sphincteric  margin  can  be  demonstrated.  These  are  of  two  principal 
types  namely — bulgings  and  clefts.  If  in  any  segment  of  the  ring 
the  normal  concavity  is  replaced  by  a  convexity  which  is  covered  by 
approximately  normal  mucous  membrane,  we  know  that  some  abnormal 


Fig.  57. — Base  of  the  Prostate  as  shown  by  Cystophotography. — {Ramon  Guileras 
A  Text-book  of  Urology,  D.  Applelon  and  Co.) 

growth  or  mass  is  invading  the  bladder  from  outside  and  below  the 
sphincter  muscle.  Again,  if  in  one  or  more  segments  of  the  sphincteric 
ring,  bulgings  or  prominences  are  found  which  come  together  and  thus 
produce  clefts,  it  is  evident  that  we  have  to  deal  with  separate  masses 
which  are  encroaching  side  by  side  on  the  sphincteric  area.  If  the  upper 
and  lateral  portions  of  the  vesical  outlet  are  normal  with  clefts  at  eight 
o'clock  and  four  o'clock,  and  if  it  is  necessary  to  depress  the  ocular  end 
of  the  instrument  to  see  the  summit  of  a  mass  situated  in  the  mid-line 
of  the  floor  of  the  sphincteric  area,  it  is  evident  that  we  are  dealing  with 
a  median  lobe  enlargement. 

Having  examined  the  region  of  the  vesical  outlet,  attention  should 
be  directed  to  the  trigonal,  ureteric,  and  post-trigonal  areas.  This 
part  of  the  examination  is  of  the  greatest  importance,  not  only  in  the 
determination  of  the  presence  of  prostatic  hypertrophy,  but  in  the  dis- 


1 54  Diagnosis 

covery  of  complications  which  usually  affect  this  portion  of  the  bladder. 
It  is  here  that  calculi  usually  lodge;  here  also  are  found  diverticula 
and  saccules,  and  complicating  tumors  of  the  bladder  wall  are  especially 
prone  to  occur  in  the  region  of  the  ureteral  orifices.  In  cases  suspected 
of  renal  complications  the  ureteral  orifices  must  be  brought  into  view, 
and  this  further  increases  the  importance  of  this  area. 

Of  great  importance  in  the  diagnosis  of  prostatic  hypertrophy  is 
the  relation  which  the  ureteral  orifices  bear  to  the  sphincteric  margin. 
In  normal  circumstances  the  vesical  outlet  represents  one  of  the 
apices  of  an  equilateral  triangle  the  sides  of  which  are  approximately 
two  and  a  half  cm.,  the  other  apices  being  represented  by  the  ureteral 
orifices.  With  an  intravesical  enlargement  of  the  prostate,  especially 
in  the  basal  area,  this  triangle,  which  is  the  trigonum  vesicae,  is  fore- 
shortened and  the  ureteral  orifices  are  frequently  out  of  sight,  being 
situated  behind  the  projecting  edge  of  the  invading  mass. 

By  introducing  the  instrument  further  into  the  bladder  and  elevating 
the  ocular  end,  a  median  lobe  may  be  compressed  by  the  shaft  of  the 
instrument  so  that  oftentimes  the  ureters  can  thus  be  brought  into  view. 
The  difficulties  of  bringing  the  ureters  into  view  and  the  estimation  of 
the  shortening  of  the  trigonum  is  a  valuable  index  of  the  degree  of  intra- 
vesical enlargement  of  the  prostate.  Large  calculi  may  occupy  the 
post-prostatic  pouch  and  escape  notice  unless  a  careful  examination  is 
made  of  the  basal  area.  We  are  also  thorough  in  our  search  for  diver- 
ticula, for  while  we  have  not  met  with  them  as  serious  post-operative 
complications  in  many  instances,  yet  the  presence  of  a  large  diverticu- 
lum may  negate  entirely  the  expected  benefit  to  be  derived  from  removal 
of  an  enlarged  prostate. 

The  patient  with  a  large  diverticulum  should  be  told  that  a  second 
operation  will  be  necessary  to  relieve  him  completely  of  symptoms  of 
prostatism.  The  residual  urine  and  all  of  its  serious  consequences  will 
continue  even  after  the  removal  of  the  enlarged  prostate. 

Having  completed  the  examination  of  the  bladder  and  the  vesical 
outlet  we  next  pay  special  attention  to  the  meati  of  the  ureters.  Here 
we  may  find  gross  evidence  of  disease,  such  as  a  plug  of  pus  projecting 
from  the  ureteral  meatus,  or  one  or  other  ureteral  meatus  may  have  lost 
its  sphincteric  control  and  stand  gaping,  wide  open.  Streams  of  cloudy 
or  bloody  fluid  may  be  seen  coming  in  spurts  from  one  or  both  ureters. 

In  the  event  of  suspected  kidney  disease  the  examination  will  have 
been  begun  with  a  double  catheterizing  cystoscope.  The  ureteral 
catheters  will  now  be  introduced  into  the  ureters,  if  there  is  good 


Cystoscopy  i^^ 

reason  to  believe  that  one  or  other  of  the  kidneys  is  surgically  diseased. 
Specimens  of  urine  are  collected  from  each  kidney. 

An  intravenous  injection  of  indigo-carmine  (lo  cc.  of  .04  per  cent, 
solution)  is  now  given  and  the  appearance  time  of  the  drug  noted. 
Specimens  of  urine  are  again  collected  in  order  to  determine  the  relative 
intensity  of  the  dye  secreted  by  the  two  kidneys. 

In  many  cases  it  is  impossible,  or  inadvisable,  to  pass  catheters 
into  the  ureters,  and  under  these  circumstances  if  kidney  disease  is  sus- 
pected the  indigo-carmine  is  injected  and  its  appearance-time  merely 
noted.  We  will  have  already  determined  in  these  cases  the  total 
functional  capacity  of  the  kidneys  as  measured  by  the  output  of  phenol- 
sulphonephthalein;  the  sole  purpose  of  the  cystoscopic  investigation 
in  this  connection  is  to  determine  the  presence  or  absence  of  gross 
lesions  of  the  kidney  that  would  under  ordinary  circumstances  demand 
surgical  treatment.  This  can  be  determined  quickly  and  safely  by 
chromo-ureteroscopy.  We  do  not  employ  the  differential  phthalein 
test  in  these  cases.  If  the  total  phthalein  output  is  normal  or  approxi- 
mately so,  and  if  indigo-carmine  is  eliminated  from  each  kidney  within 
the  normal  time  limit  there  is  no  justification  for  further  investigation 
of  the  state  of  the  kidneys  in  a  patient  who  is  in  obvious  need  of 
prostatectomy. 

It  is  desirable  to  conduct  the  cystoscopic  examination  in  an  orderly 
and  thorough  manner,  and  to  promote  thoroughness,  it  is  advisable 
to  cultivate  the  habit  of  recording  immediately  any  abnormalities  that 
may  be  met  with.  As  a  means  of  recording  the  various  fields  examined 
when  outlining  the  vesical  outlet,  the  graphic  method  described  by 
Young  is  admirable.  The  examiner  provides  himself  with  a  chart 
consisting  of  a  series  of  small  circles  arranged  around  a  common  focal 
point.  Each  circle  represents  a  cystoscopic  field  and  into  it  is  drawn 
an  outline  of  the  margin  of  the  bladder  outlet  as  it  appears  in  the 
particular  portion  under  examination.  With  the  corrected  image 
cystoscope,  the  parts  are  seen  in  their  true  relationship  although  magni- 
fied more  or  less  in  respect  to  the  proximity  or  distance  with  which  the 
lens  of  the  instrument  is  placed  in  relation  with  the  object.  We  prefer 
to  begin  the  examination  at  the  superior  or  anterior  margin  of  the  outlet 
where,  under  normal  circumstances,  the  sphincteric  margin  appears  as  a 
shallow  concavity.  In  the  presence  of  lateral  lobe  hypertrophy  with 
intravesical  growth  this  concavity  will  be  replaced  by  a  cleft  to  either 
side  of  which  bulgings  will  be  observed.  If  the  enlargement  of  the 
gland  is  symmetrical,  the  cleft  will  be  placed  in  the  midline.     When 


156  Diagnosis 

one  lateral  lobe  invades  the  bladder  to  a  greater  extent  than  its  fellow, 
the  urethra  will  be  displaced  accordingly,  and  the  cystoscopic  picture 
shows  the  cleft  displaced  to  the  side  opposite  that  of  the  lobe  which  is  the 
more  involved.  It  is  important  to  remember  that  in  the  presence  of 
intravesical  projections  of  the  prostate  one  observes  during  a  cystoscopic 
examination,  not  the  sphincteric  margin,  but  the  edge  of  the  intravesical 
growth;  the  sphincter  muscle  has  been  pushed  aside  by  the  invading 
tumor  and,  as  a  rule,  lies  far  removed  from  the  bladder  outlet. 


Fig.  58. — (Above)  Edema  Bullosum,  in  Connection  with  (below)  Bilateral  Hyper- 
TROPHiED  Prostate. — {Lewis  and  Mark.) 

Having  observed  and  recorded  the  alterations  at  the  superior 
margin  of  the  bladder  outlet,  the  instrument  is  rotated  and  "field  by 
field"  the  entire  outlet  is  examined.  With  the  examination  completed, 
the  cystoscopist  will  have  a  rather  exact  idea  of  the  type  and  extent  of 
the  intravesical  growth.  By  joining  the  arcs  of  the  different  circles 
which  he  has  drawn  on  the  chart,  a  permanent  record  of  what  he  has 
observed  is  provided. 

The  inexperienced  cystoscopist  will  perhaps  be  misled  by  clefts 
which  are  sometimes  found  at  the  superior  portion  of  the  outlet  and 
which  are  due  to  contractions  of  the  sphincter  muscle.  In  congested 
states  of  the  prostate  which  so  often  accompany  vesical  calculus,  a 
cleft  may  be  observed  in  this  same  locality.  It  is  important  also  to 
remember  that  the  pressure  of  the  shaft  or  break  of  the  instrument 


Cystoscopy  157 

will  efface  clefts  or  bulgings,  so  that  in  examining  any  given  segment  of 
the  outlet  the  lens  should  be  held  as  far  from  the  object  as  possible. 

Differential  Cystoscopic  Diagnosis. — The  cystoscope  is  of  the 
greatest  value  as  an  aid  in  the  differentiation  of  prostatic  hypertrophy 
from  vesical  calculus,  bladder  tumors,  diverticula  and  other  conditions 
which  may  give  rise  to  the  symptoms  characteristic  of  prostatism. 
When,  by  its  aid  we  have  determined  the  absence  of  intravesical  enlarge- 
ment of  the  prostate  in  a  patient  who  presents  the  symptomatic  picture 
of  benign  prostate  hypertrophy,  we  have  learned  much  of  diagnostic 
importance  by  exclusion.  In  the  absence  of  an  intravesical  cause  for  the 
patient's  suffering  a  mechanical  factor  will  probably  be  found  at  the 
beginning  of  the  urethra.  This  is  frequently  a  median  bar  formation 
or  a  sclerosis  of  the  vesical  neck,  which  may  be  either  malignant  or 
inflammatory  in  origin.  Enlargement  of  the  subcervical  group  of  glands 
is  likewise  a  cause  of  median  bar  formation,  which  must  be  differenti- 
ated from  true  prostatic  enlargement.  Chronic  prostatitis  is  of 
importance  in  this  connection  only  in  so  far  as  it  gives  rise  to  bar 
formation  or  sclerotic  changes  in  the  region  of  the  vesical  neck. 

In  rare  instances  well-circumscribed  hypertrophic  nodules  may 
invade  the  urethra  early  in  the  course  of  prostatic  hypertrophy  and  give 
rise  to  obstructive  symptoms  long  before  marked  general  hypertrophy 
of  the  prostate  is  demonstrable.  This  is  particularly  true  of  median 
lobe  hypertrophies. 

The  presence  of  these  conditions  may  be  determined  instrumentally. 
Both  the  aero-urethroscope  and  the  cysto-urethroscope  are  used  in  the 
study  of  the  deep  urethra  and  the  vesical  outlet. 

Carcinoma  of  the  prostate  gives  rise  to  the  early  production  of  a 
median  bar  but  the  nature  of  this  cannot  be  determined  cystoscopically 
in  the  absence  of  ulceration  or  other  more  characteristic  findings. 

The  rectal  examination  furnishes  more  important  diagnostic 
data  than  does  the  cystoscope  in  carcinoma  of  the  prostate.  In 
advanced  cases  when  the  carcinoma  has  caused  an  elevation  of  the 
trigonum  vesicae  and  ulceration,  and  has  otherwise  produced  a  charac- 
teristic cystoscopic  picture,  the  condition  will  certainly  be  recognizable 
by  rectal  examination.  In  cases  where  benign  hypertrophy  and  carci- 
noma of  the  prostate  co-exist  and  in  which  bleeding  is  a  prominent 
symptom  the  cystoscope  is  of  the  greatest  value  in  determining  the 
oper ability  of  the  case. 

Some  few  cases  are  met  with  in  which  a  diagnosis  of  carcinoma  of 
the  prostate  cannot  be  made  by  rectal  examination  alone,  while  the 


158  Diagnosis 

cystoscopic  data  is  conclusive.  These  are  the  rare  cases  in  which  the 
malignancy  takes  origin  from  portions  of  the  prostate  adjacent  to  the 
urethra. 

Sclerosis  of  the  proximal  urethra  and  the  vesical  outlet  commonly 
occurs  in  prostatic  carcinoma  of  the  scirrhous  variety.  It  is  difficult 
in  the  absence  of  ulceration  or  of  characteristic  induration  of  the  gland 
to  distinguish  these  cases  from  ancient  prostatitis  or  peri-prostatitis. 
Indeed,  the  products  of  inflammation  may  so  closely  mimic  malignant 
induration  as  to  render  the  diagnosis  almost  impossible.  In  the 
inflammatory  cases  there  is  more  likely  to  be  an  apparent  shortening 
of  the  prostatic  urethra  with  a  sharp  edged  median  bar  at  the  posterior 
Up  of  the  vesical  outlet.  Just  in  front  of  this  bar  will  be  observed  a 
cavity  the  lower  limit  of  which  is  represented  by  the  posterior  dechv- 
ity  of  the  verumontanum.  This  cavity  is  caused  by  an  increase  in  the 
antero-posterior  diameter  of  the  urethra,  and  the  presence  of  the  median 
bar  toward  which  the  verumontanum  is  drawn  by  contractions  of  the 
inflammatory  tissues.  In  malignant  cases  the  peri-urethral  sclerosis 
takes  the  form  of  a  non-resilient  annular  induration  which  is  more  re- 
sistant to  dilatation  than  is  inflammatory  sclerosis. 

In  the  absence  of  obstructive  causes  for  the  presence  of  residual 
urine  and  concomitant  symptoms  of  prostatism,  our  attention  is  directed 
to  the  nervous  system  as  the  cause  of  the  vesical  atony.  The  cysto- 
scope  in  these  cases  may  reveal  trabeculation  of  the  bladder  wall,  which 
in  the  absence  of  mechanical  obstruction  or  infection  is  suggestive  of 
spinal  cord  disease. 

To  recapitulate,  the  cystoscope  is  of  the  greatest  value  in  determin- 
ing the  presence  or  absence  of  obstructive  lesions  at  the  vesical  outlet, 
the  type  of  such  obstruction  and  the  type  of  operation  indicated  for  its 
removal,  and,  finally  in  the  absence  of  an  obstructive  cause  of  prostatic 
origin,  in  determining  the  nature  of  the  disease  giving  rise  to  the 
symptoms  of  prostatism. 

KIDNEY  FUNCTIONAL  TESTS 

Kidney  functional  tests  have  so  multiplied  that  a  detailed  descrip- 
tion of  all  of  them  would  be  impracticable.  We  will  discuss  here  only 
those  tests  that  are  employed  in  our  daily  work  and  in  the  results  of 
which  we  have  learned  to  place  considerable  confidence.  Furthermore, 
the  tests  will  be  discussed  only  from  the  standpoint  of  their  application 
to  prostatic  cases. 

It  has  been  our  experience  that  no  one  of  the  functional  tests  is 


Kidney  Functional  Tests  159 

infallible  and  that  judgments  based  on  the  findings  with  a  single  test 
are  very  likely  to  be  misleading.  There  is,  however,  no  justification 
for  condemning  as  useless,  all  of  the  tests  because  in  certain  instances 
one  test  fails  to  reveal  the  true  functional  capacity  of  the  kidneys. 

In  our  prostatic  work  the  percentage  elimination  of  phenolsulphon- 
phthalein  and  the  degree  of  urea  retention  in  the  blood  are  the  most 
important  criteria  of  kidney  function.  The  normal  kidneys  may  fail 
in  the  excretion  of  a  normal  amount  of  phthalein,  but  there  will  be  no 
abnormal  retention  of  urea  in  the  blood  of  an  individual  whose  kidneys 
are  functioning  normally.  If  a  poor  output  of  phthalein  occurs  in  a 
prostatic  whose  blood  urea  remains  normal  with  a  diet  containing 
ordinary  amounts  of  proteids,  we  attribute  very  little  significance  to  the 
low  output  of  the  dye. 

Diminished  phthalein  excretion  and  urea  retention  usually  occur 
together,  but  this  is  by  no  means  the  invariable  rule.  To  condemn 
functional  tests  because  of  these  exceptions  is  a  mistake.  With  proper 
interpretation  the  results  of  blood  urea  estimation  and  phthalein  eHmi- 
nation  insures,  insofar  as  the  state  of  the  kidneys  is  concerned,  the 
proper  selection  not  only  of  patients  suitable  for  prostatectomy,  but 
of  the  time  best  suited  for  the  operation. 

Indigocarmin  was  first  used  by  Heidenhain  in  1874  in  the  experi- 
mental study  of  renal  physiology.  The  fact  was  established  in  these 
experiments  that  the  drug  is  eliminated  by  the  epithelial  cells  lining 
the  convoluted  tubules.  The  test  was  not  applied  clinically  however 
until  1903,  when  Voelcker  and  Joseph  introduced  it  into  practical 
medicine. 

In  the  meantime  the  advantages  and  disadvantages  of  methylene 
blue  as  a  means  of  testing  kidney  function  had  been  carefully  deter- 
mined by  Achard  and  Castaigne.  Indigocarmin  was  soon  found  to  be 
somewhat  superior  to  methylene  blue  but  to  possess  also  some  of  its 
inherent  disadvantages.  Thus,  while  it  was  found  that  the  appearance- 
time  of  indigocarmin  was  less  than  that  of  methylene  blue,  the  same 
difficulties  of  quantitative  estimations  were  encountered  in  both  tests. 

These  difficulties  exist  for  the  very  good  reason  that  only  indefi- 
nite amounts  of  the  drugs  (not  more  than  25  per  cent,  of  indigocarmin) 
are  eliminated  by  the  kidneys,  the  fate  of  the  remaining  portions  in  the 
body  being  unknown. 

Indigocarmin  is  much  to  be  preferred  however,  because  of  its  prompt 
appearance  in  the  urine  in  maximum  intensity  within  a  comparatively 
short  period  of  time.     The  elimination  continues  for  a  period  of  from 


i6o  Diagnosis 

twelve  to  twenty-four  hours,  while  methylene  blue  may  be  found  in  the 
urine  for  periods  ranging  from  twenty-four  hours  to  several  days  in 
normal  individuals. 

Collection  of  the  entire  amount  of  either  drug  eliminated  by  the 
kidneys  is  not  essential  for  qualitative  estimations  of  kidney  func- 
tion, but  these  tests,  for  reasons  already  given,  do  not  lend  themselves 
to  accurate  quantitative  readings.  It  is  possible  however  to  make 
fairly  accurate  estimations  of  the  percentage  elimination  of  the  dyes 
by  matching  the  color  of  the  collected  specimens  of  urine  with  solu- 
tions containing  known  quantities  of  the  drugs.  In  this  manner  a 
fairly  accurate  estimation  of  the  amounts  of  the  drug  eliminated  during 
a  given  period  of  time  can  be  made.  Various  methods  and  forms  of 
apparatus  have  been  suggested  for  the  purpose  of  employing  the  in- 
digocarmin  test  quantitatively,  but  since  the  introduction  of  the 
phthalein  test  these  have  been  abandoned  in  the  majority  of  clinics. 

The  indigocarmin  test  has  a  very  definite  field  of  usefulness,  how- 
ever, and  we  would  not  limit  its  application,  as  do  some  writers,  to 
that  of  locating  the  ureteral  orifices  in  dijficult  cases.  In  fact,  it  has  been 
our  experience  that  in  differential  studies  of  kidney  function  the  indigo- 
carmin test  is  in  certain  insta,nces  equally  as  important  as  the  phthalein 
test;  we  should  be  very  loathe  indeed  to  part  with  either  one.  The  con- 
troversy that  has  arisen  in  certain  quarters  regarding  the  relative 
merits  of  these  valuable  diagnostic  aids  could  well  be  settled  by  a 
proper  appreciation  of  the  great  value  of  each  test. 

We  advocate  and  employ  the  indigocarmin  test  in  all  cases  where 
differential  studies  of  kidney  function  is  necessary,  and  in  which  ureteral 
catheterization  with  the  prolonged  instrumentation  necessary  to 
complete  a  differential  phthalein  test  is  unjustifiable;  this  includes  the 
great  majority  of  prostatics. 

In  cases  of  prostatic  hypertrophy  in  which  a  complicating  kidney 
infection  is  suspected,  thef  ollowing  method  of  procedure  may  be  carried 
out: — 

The  bladder  cavity  is  cleansed  by  repeated  washings  with  warm 
boric  acid  solution.  A  double  catheterizing  cystoscope  is  then  intro- 
duced. After  making  a  careful  survey  of  the  interior  of  the  bladder, 
paying  special  attention  to  the  region  of  the  bladder  outlet,  an  intra- 
venous injection  of  lo  cc.  of  a  0.4  per  cent,  solution  of  indigocarmin  is 
given.  The  meati  of  the  ureters  are  then  located  and  the  appearance  of 
the  drug  watched  for.  In  individuals  with  normal  kidneys  a  spurt  of 
urine  stained  an  intense  blue  will  be  observed  coming  from  each  ureter 


Indigocarmin   Test  i6i 

in  from  three  to  six  minutes  after  the  indigocarmin  solution  has  been  in- 
jected. In  certain  instances  the  appearance-time  is  prolonged  under 
normal  circumstances  to  ten  minutes.  Needless  to  say  the  solution  of 
indigocarmin  must  be  sterile  and  free  from  insoluble  particles. 

If  there  is  a  prolongation  of  the  appearance-time,  or  if  there  is  in 
addition  to  retardation  in  elimination,  a  marked  difference  in  the  inten- 
sity of  the  blue  from  one  or  the  other  side,  a  ureteral  catheter  may  be 
passed  into  the  ureter  and  a  sample  of  urine  from  the  obviously  diseased 
side  collected. 

The  experienced  cystoscopist  will  learn  a  great  deal  regarding 
kidney  function,  not  only  from  the  delay  in  the  appearance-time  of  the 
drug  in  diseased  states  of  the  kidneys,  but  also  from  the  relative  differ- 
ences in  the  intensity  of  the  blue  from  the  two  kidneys. 

This  test  obviously  lacks  the  refinements  of  the  phthalein  test  in 
differential  studies  of  kidney  function,  but  insofar  as  the  prostatic  is 
concerned,  we  have  learned  to  place  great  reliance  on  it  in  the  study 
of  complicating  surgical  lesions  of  the  kidneys. 

If  after  the  intravenous  injection  of  indigocarmin,  the  drug  fails 
to  appear  in  the  urine  from  one  kidney  within  a  period  of  fifteen  min- 
utes and  then  only  in  a  faint  spurt,  while  the  kidney  of  the  opposite 
side  excretes  the  drug  promptly  and  in  full  intensity  of  color,  there  is 
in  all  probability  a  surgical  lesion  of  one  kidney  present.  In  the  event 
of  the  prostatic  obstruction  not  demanding  immediate  attention,  it  is 
advisable  to  enlist  the  aid  of  the  ureteral  catheter,  the  differential 
phthalein  test,  and  possibly  pyelography,  to  aid  in  the  diagnosis.  If, 
however,  the  total  phthalein  output  is  satisfactory  and  the  blood  urea 
content  is  relatively  normal,  the  kidney  complication  may  be  disre- 
garded; if  the  prostatic  condition  urgently  demands  relief  the  bladder 
should  be  drained  suprapubically  at  once. 

The  further  course  of  treatment  should  be  guided  by  the  total 
percentage  output  of  phthalein,  the  urea  content  of  the  blood,  and 
the  patient's  general  condition.  These  being  found  satisfactory,  the 
prostate  should  be  removed  even  though  the  patient  has  a  diseased 
kidney  that  would  necessitate  either  removal  or  drainage  under  ordinary 
circumstances. 

The  important  consideration  in  the  average  case  of  prostatic  hyper- 
trophy coming  to  operation  is  not  the  exact  state  of  the  kidney  tissues 
pathologically,  but  whether  there  is  enough  normal  renal  tissue  remain- 
ing that  will,  when  functioning  at  its  maximum  capacity,  be  able  to 
support  life,  although  subjected  to  the  shock,  hemorrhage,  and  toxemja 
11 


i62  Diagnosis 

incident  to  anesthesia  and  operation.  This  can  best  be  determined 
by  comparing  the  total  phthalein  output  and  percentage  content  of 
kidney  retention  products  in  the  blood  before  and  after  preliminary 
treatment  designed  to  decompress  the  kidneys. 

Phenolsulphonephthalein  is  one  of  a  class  of  chemical  compounds  first 
produced  by  Remsen  through  the  action  of  orthosulphonbenzoic  acids 
upon  the  phenols.  It  consists  of  a  bright  red  crystalline  powder  which 
is  soluble  to  some  degree  in  water  but  more  so  in  alcoholic  solutions,  and 
is  freely  soluble  in  alkaline  solutions. 

The  first  indication  of  its  clinical  possibilities  came  with  the  demon- 
stration by  Abel  and  Rowntree  that  the  drug  is  non-toxic  and  non- 
irritant  when  injected  into  the  tissues.  These  observers  further  noted 
that  it  was  quickly  excreted  from  the  body,  almost  entirely  in  the  urine 
and  that  complete  elimination  of  small  quantities  took  place  within  a 
comparatively  short  period  of  time.  By  the  addition  of  alkalies  to  the 
urine  the  brilliant  red  color  of  the  drug  is  restored,  so  that  the  possi- 
bilities of  the  drug  as  an  accurate,  quantitative  colorimetric  test  of  kidney 
function  were  soon  realized.  The  elimination  of  this  particular 
phthalein  by  the  kidneys  differed  from  that  of  all  other  phthaleins,  and 
the  clinical  possibilities  of  the  drug  which  the  original  investigators 
noted  have  since  been  fully  demonstrated. 

One  of  the  remarkable  features  of  the  drug  is  that  it  is  almost 
completely  eliminated  by  the  kidneys.  After  subcutaneous  injection 
it  appears,  as  Abel  and  Rowntree  first  showed,  in  the  bile,  but  is  subse- 
quently re-absorbed  by  the  intestinal  lymphatics,  so  that  even  with 
the  administration  of  large  doses  only  traces  of  phthalein  are  to  be 
found  in  the  feces. 

After  a  series  of  animal  experiments  the  original  investigators 
came  to  the  conclusion  that  the  drug  is  ''entirely  devoid  of  toxicity, 
probably  more  so  than  sodium  chloride." 

The  interest  of  the  clinician  was  then  enlisted,  and  Geraghty, 
assisted  by  Rowntree,  began  a  study  of  its  clinical  application.  The 
results  of  these  studies  were  presented  to  the  American  Association  of 
Genito-Urinary  Surgeons  in  1910.  The  technic  then  described  has 
undergone  but  little  change  and  the  conclusions  then  arrived  at  have 
needed  but  little,  if  any,  revision. 

In  order  to  establish  a  standard  in  their  clinical  study  the  authors 
first  tested  a  series  of  cases  in  which  the  kidneys  were  thought  to  be 
normal.  A  dose  of  6  mg.  was  selected  and  with  this  amount  the 
appearance-time  of  the  drug  in  the  urine,  when  injected  intramuscularly, 


Phthalein  Test  163 

was  from  5  to  1 1  minutes,  and  the  amount  excreted  varied  from  40  to  60 
per  cent,  during  the  first  hour,  and  from  20  to  25  per  cent,  in  the  second 
hour.  The  total  normal  excretion  in  the  two  hours  varied  from  60  to  85 
per  cent.  They  found  also  that  the  percentage  output  of  the  normal 
kidneys  is  constant  irrespective  of  the  amount  of  urine,  and  that  when 
large  doses  of  the  drug  are  injected,  the  percentage  output  is  relatively 
lower  but  the  absolute  amount  is  greater. 

The  clinical  part  of  the  paper  by  Geraghty  and  Rowntree  was  a 
resume  of  the  results  of  the  phthalein  test  in  fifty-three  cases  of  pros- 
tatic h3^ertrophy.  The  results  of  these  studies  established  the  phtha- 
lein test  as  pre-eminent  among  functional  kidney  tests  in  cases  of 
enlargement  of  the  prostate.  Subsequently  the  technic  was  developed 
to  include  the  estimation  of  function  of  the  individual  kidney.  In  our 
prostatic  work  the  differential  phthalein  test  is  rarely  used,  but  we 
depend  largely  upon  the  results  of  this  test  for  the  estimation  of  total 
renal  function  in  this,  as  well  as  in  other  surgical  diseases. 

Technique  of  the  Phthalein  Test  in  Prostatic  Hypertrophy. — One-half 
hour  before  injecting  the  drug  the  patient  is  instructed  to  drink  several 
glasses  of  water.  This  will  stimulate  free  urinary  secretion,  thus  in- 
suring a  prompt  appearance  of  the  phthalein  in  the  urine,  or  rather 
removing  the  possibility  of  delayed  appearance- time  because  of  a  lack 
of  secretion. 

The  bladder  is  then  emptied  per  catheter  and  the  instrument  is 
allowed  to  remain  in  situ.  One  cc.  of  a  sterile  solution  containing  6  mg. 
of  the  drug  is  injected  intramuscularly,  preferably  into  the  lumbar  mus- 
cles. Exactness  in  dosage  is  of  vital  importance  since  even  the  slightest 
variation  will  destroy  the  accuracy  of  the  test.  We  use  an  accurately 
graduated  tuberculin  syringe  for  injecting  the  drug.  Hospital  atten- 
dants must  be  carefully  instructed  in  making  the  injection  if  mistakes 
are  to  be  avoided;  they  must  be  impressed  with  the  necessity  of  injecting 
into  the  substance  of  the  muscle,  not  into  the  skin  or  the  subcutaneous 
tissues,  exactly  one  cc.  of  the  solution. 

Having  noted  the  time  when  the  injection  was  made,  the  urine  which 
flows  from  the  catheter  is  collected  in  a  test  tube  containing  a  small 
quantity  of  25  per  cent,  sodium  hydroxide  solution.  The  initial  appear- 
ance of  the  drug  in  the  urine  is  denoted  by  a  pink  color  in  the  alkahne 
solution  which  quickly  changes  to  a  brilliant  red.  The  appearance- 
time  of  the  drug  is  then  recorded.  The  catheter  is  now  corked  and  the 
urine  is  allowed  to  accumulate  in  the  bladder  for  a  period  of  one  hour, 
when  it  is  drained  into  a  suitable  receptacle  which  is  then  set  aside 


164  Diagnosis 

while  the  collection  of  the  second  hour  specimen  is  being  made.  The 
two  containers  are  then  sent  to  the  laboratory  for  a  colorimetric 
determination  of  the  percentage  amounts  of  phthalein. 

In  estimating  the  kidney  function  in  patients  who  have  no  residual 
urine  it  is  unnecessary  to  employ  a  catheter  except  in  cases  where 
accuracy  in  determining  the  appearance-time  of  the  phthalein  is  de- 
sired. These  patients  are  instructed  to  void  at  the  end  of  one  hour  and 
ten  minutes  and  two  hours  and  ten  minutes  after  the  injection  of  the 
drug,  ten  minutes  being  added  for  the  delay  in  excretion. 

The  estimation  of  the  percentage  of  excretion  of  the  drug  is  a 
matter  of  commendable  simplicity.  To  the  specimens  is  added 
sufficient  sodium  hydroxide  to  make  the  urine  strongly  alkaline.  If  the 
urine  contains  large  quantities  of  ropy  muco-pus  and  blood  it  should  be 
filtered  and  well  diluted  before  the  alkali  is  added,  otherwise  the 
readings  will  not  only  be  difficult  but  in  accurate.  An  acid  urine 
containing  phthalein  is  yellowish  brown  in  color;  this  changes  to  a 
brilliant  Bordeaux  red  when  alkalies  are  added. 

After  thorough  alkalinization  the  specimens  are  placed  in  graduates 
or  flasks  of  1000  cc.  capacity  and  distilled  water  is  added  to  make 
500  cc.  If  the  resulting  solution  has  a  fairly  deep  red  color  the  dilu- 
tion is  increased  to  1000  cc.  In  estimating  small  percentages  of  phtha- 
lein it  is  much  easier  and  more  accurate  to  employ  lower  dilutions  and 
divide  the  results  rather  than  to  attempt  to  estimate  the  percentage 
amount  of  the  drug  in  very  faintly  colored  solutions. 

The  estimations,  which  may  be  made  with  any  one  of  the  standard 
colorimeters,  should  not  be  deferred,  especially  if  the  solution  has  been 
alkalinized,  since  the  red  color  gradually  fades  if  the  solution  is  allowed 
to  stand. 

In  doing  differential  functional  studies  of  the  kidneys  the  intra- 
venous method  of  administering  phthalein  is  preferable,  since  the  rate 
of  elimination  is  much  more  rapid.  As  mentioned  above,  we  rarely 
employ  phthalein  in  differentia]  kidney  studies  of  prostatics.  We 
prefer  to  rely  upon  the  less  accurate,  though,  in  our  judgment,  more 
practical  indigocarmin  test  in  these  aged  individuals  in  whom  long- 
continued  instrumentation  is  inadvisable.  We  advise  the  reader  who 
desires  a  detailed  discussion  of  the  phthalein  test  in  all  of  its  phases  to 
consult  the  writings  of  J.  T.  Geraghty;  there  he  will  find  described  in 
the  thoroughness  characteristic  of  the  scientific  work  of  this  writer  the 
various  methods  of  using  the  test,  and  an  interpretation  of  the  results 
obtained  both  in  health  and  in  disease. 


Phthalein   Test  165 

In  normal  individuals  an  average  of  50  per  cent,  of  phthalein  is 
eliminated  during  the  first  hour,  and  after  intramuscular  injection  most 
of  it  is  eliminated  during  the  first  two-hour  period.  As  Geraghty  has 
shown,  the  moderately  diseased  kidney  will  continue  to  excrete  a  fair 
amount  during  the  third  and  fourth  hours.  Slight  changes  in  function 
can,  he  says,  be  most  accurately  demonstrated  by  one  hour's  collection 
following  an  intramuscular  (lumbar)  injection.  We  are  fond  of  com- 
paring the  rates  of  eh'mination  during  the  first  and  third  hours.  A 
relatively  late  high  percentage  output  indicates  secretory  inactivity  of 
the  renal  epithelium  if  not  actual  disease. 

The  Phthalein  Test  in  Cases  of  Prostatic  Hypertrophy. — The  kidneys 
of  practically  all  prostatics  are  functionally  below  par.  This  is  usually 
due  to  mechanical  interference  with  renal  function  incident  to  urinary 
obstruction,  but  is  often  contributed  to  by  antecedent  nephritis  or  infec- 
tions complicating  the  enlargement  of  the  prostate. 

Actual  destruction  of  the  renal  parenchyma  may  occur  through  the 
action  of  bacteria  or  it  may  merely  represent  pressure  atrophy  secondary 
to  lower  urinary  obstruction.  More  often  actual  destruction  of  renal 
tissue  has  not  occurred,  and  the  diminished  function  may  be  improved  by 
treatment.  The  purpose  of  the  functional  tests  is  to  determine  the 
presence  of  these  changes  and  to  estimate  as  accurately  as  possible 
the  reserve  capacity  of  the  kidneys. 

We  do  not  like  to  discard  as  useless  those  tests  upon  which  so  much 
dependence  was  placed  in  the  past.  We  continue  to  note  most  care- 
fully the  specific  gravity  and  total  quantity  of  the  urine  and  the  out- 
put of  urea  and  total  solids.  A  persistently  low  specific  gravity  of 
the  urine  in  a  case  of  prostatic  hypertrophy  makes  us  quite  as  appre- 
hensive as  to  the  outcome  of  operation  as  does  a  low  percentage  output 
of  phthalein. 

A  low  output  of  phthalein,  while  indicative  of  renal  derangement, 
may  be  temporary.  We  have  operated  upon  a  considerable  number 
of  patients  in  whom  prostatectomy  had  been  refused  by  other  surgeons 
because  of  a  low  output  of  phthalein,  and  have  had  good  results  not- 
withstanding. 

In  answer  to  a  questionnaire  relative  to  the  value  of  kidney  func- 
tional tests  which  was  sent  to  numerous  operators,  one  correspondent 
tells  us  that  several  of  his  patients  who  were  refused  operation  because 
of  a  low  phthalein  output  were  successfully  operated  upon  elsewhere. 
In  this  experience  he  finds  reason  for  utter  condemnation  of  the  test. 
He  unfortunately  interpreted  the  low  output  of  phthalein  in  these 


1 66  Diagnosis 

cases  as  evidence  of  irremediable  kidney  destruction,  whereas  in  fact 
it  probably  indicated  a  temporary  abeyance  in  kidney  function  due  to 
removable  causes. 

A  prolongation  in  the  appearance- time  of  phthalein  and  a  decrease  in 
the  percentage  output  of  the  drug  in  prostatics  are  danger  signals, 
but  they  do  not  necessarily  indicate  the  inoperability  of  any  given  case. 
It  is  necessary  in  these  cases  to  employ  preliminary  treatment  and  to 
continue  it  until  a  relatively  normal  function  of  the  kidneys  is  re- 
established before  prostatectomy  is  undertaken.  This  includes  decom- 
pression of  the  kidneys  either  by  means  of  the  catheter  or  by  cystostomy, 
together  with  the  administration  of  large  quantities  of  water  by  mouth 
and  by  rectum,  or  in  rare  instances  by  subcutaneous  injection.  Diure- 
tics and  urinary  antiseptics  are  sometimes  indicated  and  may  be  of 
some  benefit.  Suprapubic  cystostomy  under  local  anesthesia  is,  we 
believe,  less  dangerous  than  difficult  urethral  instrumentation. 

Cases  are  occasionally  reported,  such  as  the  one  mentioned  by 
Keyes,  in  which  there  was  total  failure  in  phthalein  elimination,  yet 
the  patient  was  successfully  operated  upon,  not  once  but  several  times, 
and  never  showed  any  evidences  of  the  loss  of  kidney  function  other 
than  the  failure  to  eliminate  phthalein.  Unless  the  initial  test  shows 
an  extremely  low  output  of  phthalein  we  are  not  especially  concerned 
with  its  prognostic  significance.  However,  if  the  percentage  output  of 
the  drug  does  not  increase  or  continues  to  diminish  under  preliminary 
treatment,  we  feel  the  greatest  concern  over  the  situation.  The 
question  arises  under  these  circumstances  whether  an  attempt  to  enu- 
cleate the  prostate  is  justifiable.  If  the  ideals  in  preliminary  treatment 
have  been  fulfilled  and  if  in  spite  of  this  there  is  blood  retention  of  urea 
in  proportion  to  the  diminished  excretory  powers  of  the  kidneys  as 
measured  by  phthalein,  we  advise  against  prostatectomy.  In  certain 
cases  cystostomy  is  necessary  and  the  patient  must  be  provided  with  a 
permanent  suprapubic  drain  and  urinal  attachment. 

In  the  opinion  of  Geraghty  diminished  kidney  function  in  prosta- 
tics due  to  infection  has  a  much  graver  significance  than  lowered 
function  dependent  upon  interstitial  nephritis.  With  this  we  agree 
as  far  as  the  dangers  of  immediate  operation  are  concerned,  but  we 
would  prefer  a  case  of  the  infectious  type  with  the  hope  of  ultimate 
successful  prostatectomy  to  one  with  a  dangerously  low  kidney  function 
resulting  from  interstitial  nephritis.  In  the  former,  we  may  expect 
response  to  judicious  preliminary  treatment,  in  the  latter  the  kidney 
destruction  is  irreparable. 


Phthalein   Test  167 

To  state  in  terms  of  percentage  output  of  phthalein  when  prostatec- 
tomy can  be  safely  undertaken  is  impossible.  It  is  only  through  the 
employment  of  this  and  other  tests  in  conjunction  with  suitable  prehmi- 
nary  treatment  that  the  functional  reserve  capacity  of  the  kidneys  can 
be  measured. 

The  phthalein  test  is  unquestionably  of  value  but  the  kidney  is 
only  one  of  several  organs  upon  the  proper  functioning  of  which  the 
success  of  prostatectomy  depends.  The  operation  should  not  be  under- 
taken until  the  cardiac,  digestive,  metaboUc,  vasomotor,  and  other 
functions  are  known  to  be  relatively  normal. 

We  have  already  remarked  upon  the  impossibility  of  determining 
accurately  in  every  instance  by  means  of  the  phthalein  test,  the  ability 
of  the  kidneys  to  weather  the  strains  incident  to  prostatectomy.  This 
was  well  shown  by  Braasch  and  Thomas  who  in  1914  reported  the  re- 
sults of  the  phthalein  test  in  168  cases  of  prostatic  hypertrophy.  After 
calling  attention  to  the  impossibility  of  selecting  any  fixed  percentage 
output  as  the  operative  danger  line,  they  mention  a  20  per  cent,  out- 
put in  two  hours  as  the  low  level  of  even  comparative  safety  at  which 
operation  may  be  undertaken.  They  then  mention  a  number  of  cases 
with  a  low  percentage  output  of  phthalein  that  recovered  and  a  num- 
ber with  a  high  percentage  output  of  the  drug  that  died  after  prosta- 
tectomy. There  were  eleven  patients  in  the  series  whose  kidneys 
eliminated  less  than  20  per  cent,  of  phthalein.  All  of  these  patients 
recovered  after  removal  of  the  prostate  except  one  whose  death  re- 
sulted from  cardiac  failure.  In  two  instances  patients  whose  kidneys 
secreted  only  a  trace  of  phthalein  in  two  hours  recovered  promptly 
from  operation.  Several  cases  in  this  series  with  normal  percentage 
outputs  for  the  two-hour  period  died  of  uremia  following  prostatectomy. 

These  observations  have  been  fully  confirmed  in  our  experience. 
One  of  our  patients,  a  man  aged  69  years,  who  had  a  phthalein  output 
persistently  below  17  per  cent,  recovered  promptly  after  prostatectomy; 
another  on  admission  to  the  hospital  had  a  phthalein  output  of  29  per 
cent,  which  gradually  dropped  to  12  notwithstanding  marked  improve- 
ment in  the  general  physical  condition;  this  patient  had  an  uninter- 
rupted operative  convalescence.  A  third  patient  with  a  phthalein 
output  of  52  per  cent,  promptly  died  of  uremia  after  operation;  a 
fourth,  aged  72  years,  with  a  phthalein  elimination  of  78  per  cent,  died 
in  uremic  coma  after  prostatectomy.  These  results  with  the  phthalein 
test  have  occurred  in  our  experience  with  comparative  frequency. 
Nevertheless  they  must  be  considered  exceptions  to  the  general  rule 


1 68  Diagnosis 

that  this  test  usually  gives  an  accurate  index  of  kidney  function.  The 
test  is  without  doubt  of  prognostic  value;  its  value  is  much  enhanced 
by  comparison  with  the  blood  urea  content. 

Illustrative  of  the  value  of  the  phthalein  test  in  gauging  the  im- 
provement in  kidney  function  with  treatment  is  the  case  of  a  patient 
who  was  admitted  to  the  Lankenau  Hospital  on  5-11-15  with  a  total 
failure  of  phthalein  ehmination;  next  day  the  percentage  output  was  10; 
four  days  later  it  reached  21  per  cent,  and  five  days  later  it  had  risen 
to  30  per  cent.  The  prostate  was  then  removed  and  the  patient 
promptly  recovered. 

The  Mayos  are  of  the  opinion  that  the  patient's  general  condition 
is  more  important  as  a  prognostic  index  than  the  results  of  the  phthalein 
test,  and  that  a  stationary  or  decreasing  phthalein  output  is  not  a  con- 
traindication to  operation  provided  the  general  condition  is  improving. 
We,  too,  are  guided  largely  by  the  general  condition  of  the  patient,  but 
we  must  confess  that  a  decreasing  phthalein  output  when  accompanied 
by  a  rising  blood  urea  notwithstanding  appropriate  treatment,  is  looked 
upon  by  us  as  of  serious  prognostic  significance. 

Practically  every  individual,  we  repeat,  demands  treatment  before 
operation.  In  every  case  there  is  a  time  when  the  maximum  efficiency 
of  the  vital  organs  is  reached.  The  correct  interpretation  of  the  vari- 
ous functional  tests  is  a  matter  of  experience.  Such  interpretation 
is  not  merely  a  mathematical  formula,  but  depends  largely  upon 
clinical  knowledge  without  which  no  surgeon  can  be  a  successful 
prostatectomist. 

Tests  of  Retention  aim  to  estimate  kidney  function  by  measuring  the 
increase  in  the  blood  of  substances  that  should  have  been  eliminated  by 
the  kidneys.  Practically  all  of  the  ash  of  protein  derivatives  and  non- 
protein nitrogen  is  eliminated  by  the  kidneys.  Failure  of  renal  function 
is  quickly  followed  by  accumulation  of  these  substances  in  the  blood. 
A  concentration  of  urea,  0.5  grams,  and  of  the  total  incoaguable  nitro- 
gen, 0.6  grams  per  litre  of  blood,  have  been  the  accepted  normal  level, 
but  FoUn  and  Dennis  have  found  that  a  concentration  of  non-protein 
nitrogen,  26  mg.  and  urea  nitrogen,  13  mg.  per  100  grams  of  blood,  is  the 
normal  concentration. 

According  to  Geraghty  "no  great  prognostic  significance  can  be 
attached  to  concentrations  less  than  0.55  gms.  per  litre.  Increase  in 
the  content  of  blood  urea  is  not  always  found  in  nephritic  men  in  the 
presence  of  impending  uremia,  while  an  increase  in  the  m'trogen  con- 
tent of  the  blood  is  found  in  diseases  other  than  nephritis.     With  this, 


Retention  Tests  169 

as  with  other  tests,  there  are  therefore  notable  exceptions  that,  unless 
recognized,  will  negate  the  value  of  the  test  as  a  practical  aid  in  the 
diagnosis  and  prognosis  of  kidney  disease." 

Urea  exists  throughout  the  body  in  practically  the  same  concentra- 
tion. In  the  normal  individual  it  is  delivered  to  the  kidneys  in  a 
definite  concentration  which  latter  depends  almost  exclusively  upon  the 
protein  content  of  the  diet.  Normally  urea  constitutes  about  one-half 
of  the  solids  in  solution  in  the  urine,  about  30  gm.  being  eliminated 
by  the  kidneys  of  a  healthy  individual  in  twenty-four  hours. 

According  to  Fohn  the  urea  is  produced  from  the  products  of 
proteid  digestion  by  the  liver  whence  it  goes  to  the  blood  to  be  elimi- 
nated by  the  kidneys  without  entering  into  tissue  formation.  Ob- 
viously the  influence  of  diet  is  most  important.  Mosenthal  and 
Lewis  call  attention  to  bodily  tissue  destruction  in  diseased  states 
as  a  cause  of  blood  urea  accumulation.  This  factor  must  be  taken  into 
account  when  estimating  the  concentration  of  urea  in  the  blood,  es- 
pecially in  cases  where  an  adequate  degree  of  renal  failure  cannot 
be  demonstrated  by  the  phthalein  and  other  tests  to  explain  it. 

The  total  kidney  function  cannot  be  determined  with  accuracy  by 
measuring  the  urea  content  of  the  urine.  Ambard's  constant,  however, 
which  is  based  on  laws  governing  the  proportionate  amounts  of  urea  in 
the  blood  and  urine  of  healthy  individuals  is  considered  by  many,  and 
especially  by  French  urologists  a  reliable  means  of  estimating  kidney 
function.  This  method  has  not  gained  in  popularity  in  this  country, 
nor  has  cryoscopy  met  with  much  favor  among  American  urologists. 
In  our  own  clinic,  and  this  applies  we  believe,  to  most  of  the  clinics  in 
America,  the  test  of  retention  most  frequently  employed,  and  the  one  on 
which  most  rehance  is  placed,  is  the  estimation  of  the  urea  nitrogen 
in  the  blood.  Urea  constitutes  about  70  per  cent,  of  the  total  nitrogen 
of  the  blood  and  variations  in  its  concentration  are  associated  with 
parallel  variations  in  the  total  non-proteid  nitrogen.  As  mentioned, 
above  a  concentration  of  urea  13  mg.  per  100  cc.  of  blood  is  said  by 
Folin  and  Dennis  to  be  normal. 

The  urea  test,  like  all  other  laboratory  tests  for  renal  insuflBciency, 
is  merely  an  adjunct  to  the  diagnosis  and  prognosis.  All  laboratory 
tests,  which  are  of  great  value  when  properly  interpreted,  may  be 
productive  of  gross  errors  if  clinical  experience  and  common  sense  are 
not  used  liberally  in  their  practical  application. 


1 70  Diagnosis 

REFERENCES  (CHAPTER  VIII) 

Abel  and  Rowntree:  Jour.  Pharm.  and  Exper.  Therap.,  1909,  i,  231; 

Achard   and    Castaigne:    L'exam.    clinique    des   fonctions   renales  par   1'   elimination 

proroquee.     Paris,  1900. 
Albarran  and  Halle:  Annales  de  Mai.  d.  Org.  Gen.-Urin.,  1900,  xviii,  113. 
Ambard:  Surg.,  Gyn.  and  Obst.,  1914,  xix,  468. 
Belfield,  Wm.  T.:  Vesical  Obstruction  by  Diseased  Seminal  Vesicles.     Trans.  Amer.  Urol. 

Assoc,  191 5,  ix,  p.  254. 
Boyd:  Phenolsulphonephthalein  in  Functional  Tests  of  the  Kidneys.     Jour.  Amer.  Med. 

Assoc,  191 2,  Iviii,  620. 
Braasch,  W.:  St.  Paul  Med.  Jour.,  1915,  xvii,  i. 
Braasch  and  Thomas:  Jour.  Amer.  Med.  Assoc,  1915,  Ixiv,  9. 
Burns,    J.    E.:  Thorium,    A   New   Agent  for  Pyelography.     Jour.  Amer.  Med.  Assoc 

Ixiv,  2126-27. 
Cabot,  H.,  and  Young,  E.  C,  Jr.:  Phenolsulphonephthalein  as  a  Test  of  Renal  Func- 
tions.   Trans.  Amer.  Assoc,  Gen.-Urin.  Surg.,  191 1,  vi,  136. 
Cameron,  D.  F.:  A  Comparative  Study  of  Sodium  lodid  as  an  Opaque  Medium  in  Pyelo- 
graphy.   Archives  of  Surgery,  1920,  i,  184. 
Crenshaw,  J.  L.:  Post-operative  Complications  Following  Prostatectomy.    Jour.  Amer. 

Med.  Assoc,  191 7,  Ixviii,  611. 
Cumston:  Am.  Jour.  Urol.,  1913,  ix,  509. 
Cunningham,  John  H.:  Stricture  of  the  Deep  Urethra  Simulating  Prostatic  Obstruction. 

Trans.  Amer.  Urol.  Assoc,  1915,  ix,  282;  Annals  of  Surgery,  1905,  xli,  590. 
Descuns:  Am.  Jour.  Urol.,  1915.  xi,  373. 
Folin:  Amer.  Physiol.  Jour.,  1905,  xiii,  45. 
Folin  and  Dennis:  Jour.  Exp.  Chem.,  1910,  iv,  429. 
Fowler,  H.  A.:  Trans.  Amer.  Urol.  Assoc,  1915,  ix,  266. 
Freyer:  Arch.  Internat.  de  Chirur.,  1914,  vi,  388. 
Gebele:  Beitr.  z.  klin.  Chir.,  1913,  Ixxxviii,  657. 
Gebsau:  Jour.  Amer.  Med.  Assoc,  1910,  liv,  1372. 
Geraghty  and  Rowntree:  Jour.  Amer.  Med.  Assoc,  1913,  Ivii,  811. 
Geraghty,  Rowntree  and  Cary:  Annals  of  Surg.,  1913,  Ivii,  800. 
Goldstein,    A.  E.:  The    Diagnostic   and    Prognostic  Value  of  Blood  Urea  in  Urology. 

Jour.  Amer.  Med.  Assoc,  1918,  Ixxi,  24;  1957. 
Gradwohl  and  Scherck:  A  Study  of  Chemical  Blood  Findings  in  Various  Conditions  in 

Comparison  with  the  Phenolsulphonephthalein  Output.     Trans.  Amer.  Urol.  Assoc, 

1917,  xi,  195. 
Hall,  S.  S.:  A  Study  of  Seventy-five  Tabetic  Bladders.     Surg.,  Gyn.  and  Obst.,  1915, 

XX,  176. 
Hyman,  A.:  Annals  of  Surgery,  1914,  lix,  i. 
Judd:  Surg.,  Gyn.  and  Obst.,  1915,  xx,  274. 
Kendall,  E.  C:  The  Fate  of  Phenolsulphonephthalein  when  Injected  into  the  Animal 

Organism.     Factors  other  than  the  Kidney  Influencing  "Retention;"  Preliminary 

Report.     Jour.  Amer.  Med.  Assoc,  191 7,  Ixviii,  343. 
Ktimmell:  Ztschr.  z.  klin.  Chir.,  1913,  ii,  18. 
Legueu:  Jour.  d'Urologie,  Paris,  191 2,  ii,  289-424. 
Lewis,  Bransford:  Trans.  Amer.  Urol.  Assoc,   1915,  ix,   274;  Annals  of  Surgery,   1915, 

bd,  276. 
Malhont,    A.:  Observations   on   Incipient   Hypertrophy  of  the  Prostate.    Jour.  Amer. 

Med.  Assoc,  1895  xxv,  1337. 
Mallory,  M.  J.:  Acidosis  and  Renal  InsuflSciency.     Wash.  M.  Ann.,  1917,  xvi,  11. 


References 


171 


Marion,  G.:  La  Cystoscopie  dans  L'Hypertrophie  de  la  Prostate,  Jour.  d.  Urol.,  1912,  ii,  2. 

McGrath:  Jour.  Amer.  Med.  Assoc,  1914,  Ixiii,  1012. 

Mosenthal  and  Lewis:  A  Comparative  Study  of  Tests  of  Renal  Function.    Jour.  Amer. 

Med.  Assoc,  191 7,  Ixvii,  933. 
Motz:  Annal.  d.  Org.  Gen.-Urin.,  1907,  i,  162. 
Nicholson,   E.,  and  Hainworth,   E.   M.:  Primary  Sarcoma  of  Prostate  in  Boy.     British 

Med.  Jour.,  1919,  i,  378. 
Osgood:  Trans.  Amer.  Assn.  Genito-Urin.  Surg.,  i9i3,viii,  138. 
Parmenter:  Sarcoma  of  the  Prostate.     Surg.,  Gyn.  and  Obst.,  1917,  xxiv,  838. 
Pauchet:  Sarcoma  de  la  Prostate.    Jour,  d'urol.  med.  et  chir.,  191 2,  ii,  367. 
Powers:  Annals  of  Surg.,  1908,  xlvii,  58. 

Proust  and  Vion:  Sarcome  de  la  Prostate.     Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1907,  i,  721. 
Remsen:  Amer.  Chem.  Jour.,  1884-5,  ^'h  180.  Ibid.,  xx,  257. 
Rowntree  and  Geraghty:  Jour.  Pharm.  and  Exper.  Therap.,  1910,  579;  Arch.  Int.  Med., 

191 2,  ix. 
Rowntree,  Geraghty  and  Marshall:  Surg.,  Gyn.  and  Obst.,  19 14,  xviii,  196. 
Sabawalo:  Brit.  Med.  Jour.,  1915,  ii,  256. 
Simons,  S.:  A  Case  of  Urinary  Obstruction  Due  to  Enlargement  of  the  Anterior  Lobe  of 

the  Prostate.     The  Jour,  of  Urol.,  1919,  iii,  43. 
Van  Fresch:  Die  Krankheiten  der  Prostata,  1910. 
Voelcker  and  Joseph:  Deutsche  Med.  Wchnschr.,  1904,  XXX,  536. 
Walker:  Lancet,  1908,  i,  1054. 
Weld,    E.    H. :  The   Use  of   Sodium  Bromide  in  Roentgenography.    Jour.  Amer.  Med. 

Assoc,  1918,  Ixxi,  iiii;  Thesis,  University  of  Minnesota,  May,  1919. 
Wilson  and  McGrath:  Surg.,  Gyn.  and  Obst.,  1911,  xiii,  647. 
Young:  Annals  of  Surgery,  1909,  xlix,  1232.    Jour.  Amer.  Med.  Assoc.,  1906,  xlvi,  699. 

Cabot's  Modern  Urology,  i,  657-723,  The  Johns  Hopkins  Hospital  Reports,  1906,  xiv; 

Trans,  of  the  Internal.  Assoc  of  Urology,  London,  191 1;  Trans.  Seventeenth  Internal. 

Congress  of  Medicine,  London,  1913. 
Young  and  Frontz:  Jour.  Amer.  Med.  Assoc,  1917,  Ixviii,  526.  1 


CHAPTER  IX 
PROGNOSIS 

A  question  of  considerable  importance  and  much  interest  in  con- 
nection with  enlargement  of  the  prostate  is  that  of  prognosis.  In  few 
other  diseases  is  it  so  necessary  for  the  surgeon  to  know  what  may  be 
accomphshed  by  the  various  methods  of  treatment,  and  in  probably 
no  other  class  of  cases  is  he  more  severely  blamed  for  errors  in  judg- 
ment. It  is  not  sufficient,  indeed  it  is  neither  ethical  nor  humane, 
to  hope  that  the  patient  will  die  of  some  intercurrent  affection  before 
any  necessity  arises  for  instituting  active  treatment  on  behalf  of  his 
enlarged  prostate;  and  hence  every  physician  or  surgeon  who  has  such 
cases  under  his  charge  must  give  careful  thought  and  attention  to  each 
individual  patient,  and  must  know  whether  the  expectation  of  life  will 
be  lengthened  or  decreased  by  the  treatment  he  proposes,  or  whether 
the  certainty  of  a  hfe  of  considerable  discomfort  for  a  rather  prolonged 
period  is  not  less  to  the  patient's  ultimate  advantage  than  the  immedi- 
ate risk  of  life  incurred  by  a  somewhat  severe  and  shocking  operation, 
wljich,  if  successful,  will  enable  the  patient  to  live  out  his  natural  term 
of  hfe  in  ease  and  comfort. 

There  are,  then,  two  main  questions  to  be  solved  in  this  connection: 
first,  whether  the  patient's  life  can  be  saved,  prolonged,  or  at  least  not 
sacrificed  by  the  treatment  to  be  pursued — that  is  to  say,  the  question 
of  mortality;  and,  second,  whether  the  patient's  sufferings  will  be  re- 
heved  wholly  or  in  part,  or  whether  no  change  at  all  can  be  obtained — 
that  is,  the  question  of  final  functional  results. 

Under  medical  treatment  and  catheterism  there  is  practically 
no  possibility  of  directly  terminating  the  patient's  hfe ;  with  the  under- 
standing that  every  antiseptic  precaution  be  taken  in  catheterization, 
his  life  may  even  be  prolonged,  and  in  certain  cases  made  very  comfort- 
able. Many  a  patient  who  has  to  pass  a  catheter  only  once  or  twice  in 
the  twenty-four  hours  will  live  a  Hfe  of  perfect  ease,  and  will  round  out 
his  days  without  interruption.  But  where  the  catheter  has  to  be  passed 
frequently — that  is  to  say,  as  often  as  four  to  six  times  in  the  twenty- 
four  hours — or  where  its  passage  at  even  longer  intervals  is  attended 
with  pain  or  difficulty,  catheterism  must  be  considered  at  the  present 

172 


Catheter   Life  173 

day  an  insufficient  remedy,  except  in  those  who  are  aheady  on  the 
threshold  of  the  grave.  The  expectation  of  hfe,  moreover,  in  patients 
treated  by  catheterization,  has  been  shown  by  Harrison  and  by  Lydston 
to  be,  on  the  average,  no  more  than  four  or  five  years;  so  that  it  is  clear 
that  the  life  of  the  average  patient  is  shortened  by  such  treatment. 

Squier  of  New  York  states  that  50  per  cent,  of  unoperated  patients 
will  die  within  five  years  from  the  time  of  onset  of  obstructive  symptoms 
where  catheterization  is  unnecessary.  The  institution  of  catheter 
life,  he  adds  will  shorten  the  expectation  of  life  to  two  years  and  eight 
months  on  the  average  and  increase  the  mortality  to  623^  per  cent, 
within  the  shortened  period. 

We  have  a  patient  who  has  carried  an  in-lying  catheter  for  9  years. 
He  continues  very  well.  During  this  time  absolutely  no  urine  has 
been  passed,  except  by  catheter,  and  there  is  but  a  mild  grade  of  cystitis. 

The  next  mildest  form  of  treatment  is  drainage  of  the  bladder.  By 
this  means  may  be  obtained  rehef  of  the  cystitis,  and  consequently  of 
the  tenesmus,  pain,  and  general  unrest,  in  a  certain  number  of  cases.  In 
our  opinion,  it  is  applicable  chiefly  to  those  in  a  very  debilitated  condi- 
tion, or  to  the  very  old.  Drainage  by  a  permanent  catheter  intro- 
duced through  the  urethra  can  seldom  long  be  endured,  and  is  usually 
only  to  be  employed  in  preparing  the  bladder  for  a  radical  operation. 
The  successes  of  Thompson,  McGuire,  and  others  in  treating  these  pa- 
tients many  years  ago  by  means  of  suprapubic  permanent  drainage, 
and  of  Harrison  by  means  of  a  perineal  tube,  should  not  be  forgotten 
at  the  present  day;  and  while  we  recognize  the  inadequacy  of  such 
methods  to  restore  the  patient  to  his  normal  condition,  yet  in  a  limited 
number  of  cases  they  are  still  useful.  Especially  is  this  so  in  patients 
with  very  bad  cystitis,  and  where  some  immediate  relief  is  imperative. 
In  such  cases  so  radical  an  operation  as  prostatectomy  will  almost 
surely  kill,  unless  time  can  be  obtained  to  relieve  the  cystitis,  to  get  the 
kidneys  into  fair  condition,  and  to  improve  the  general  health  of 
the  patient. 

In  such  patients,  the  two-stage  operation  is  the  method  of  choice. 
In  some  few  instances  it  is  necessary  to  form  a  permanent  suprapubic 
fistula  and  then  drain  the  bladder  for  a  prolonged  period  of  time  before 
attempting  the  removal  of  the  prostate.  Rarely  indeed,  do  we  find 
it  impossible  to  complete  the  final  stage  of  the  operation  with  compara- 
tive safety  to  the  patient  after  preHminary  drainage  of  the  bladder. 

Primary  Mortality. — It  is  the  concensus  of  opinion  among  surgeons 
that  the  primary  mortality  rate  is  slightly  less  following  perineal 


1 74  Prognosis 

prostatectomy  than  that  following  the  suprapubic  operation.  In 
this  opinion  we  concur  notwithstanding  the  fact  that  our  collected 
series  of  cases  fails  to  confirm  this  long  accepted  belief.  These  statistics 
are  collected  from  many  sources  and  include  the  results  of  operators  of 
both  great  and  small  experience.  Undoubtedly  the  primary  mortality 
rate  is  much  or  more  dependent  upon  the  care  with  which  cases  are 
selected  for  operation,  and  upon  the  thoroughness  with  which  pre- 
operative treatment  is  carried  out  than  upon  the  type  of  operation 
selected  or  the  skill  of  the  individual  who  performs  it.  Our  list  includes 
approximately  twenty-five  hundred  cases  but  does  not  include  the  pub- 
lished statistics  of  the  recognized  leaders  in  suprapubic  and  perineal 
prostatectomy.  We  have  purposely  omitted  the  results  of  the  work 
of  these  few  men  for  the  reason  that  we  are  now  attempting  to  ascertain 
the  average  mortality  of  the  operation  of  prostatectomy  as  it  is  per- 
formed throughout  the  country. 

There  exist  only  slight  differences  in  the  operative  mortality 
following  the  two  types  of  operations  in  the  hands  of  the  most  experi- 
enced men.  The  suprapubic  operation  is  a  much  safer  procedure  for 
the  occasional  operator  than  the  perineal  prostatectomy,  as  is  well  illus- 
trated by  the  much  higher  mortality  rate  for  the  latter  operation  as 
reported  by  surgeons  working  in  smaller  communities. 

Freyer  has  recently  reported  a  series  of  1550  suprapubic  prosta- 
tectomies with  a  general  mortality  of  5.33  per  cent.  The  death  rate 
among  the  first  hundred  cases  in  this  series  was  10  per  cent,  while 
among  the  last  two  hundred  cases  it  has  been  only  3  per  cent.  Young's 
mortality  rate  with  the  perineal  operation  is  slightly  less  than  4  per 
cent.  In  our  collected  series  of  cases  the  death  rate  following 
the  perineal  operation  is  10.9  per  cent,  in  contrast  to  the  6.9  per 
cent,  mortality  succeeding  suprapubic  prostatectomy.  Although 
fully  cognizant  of  the  unreliability  of  most  statistics,  we  are  inclined  to 
believe  that  these  figures  express  in  a  general  way  the  relative  dangers 
of  the  two  operations  in  the  hands  of  the  average  surgeon.  Statistics 
collected  from  other  sources  would  undoubtedly  yield  different  results, 
but  we  believe  that  these  figures  are  correct.  If  the  cases  operated 
upon  by  the  more  experienced  men  among  the  group  who  were  good 
enough  to  furnish  us  the  data,  i.e.,  if  all  series  of  one  hundred  or  more 
cases  are  eliminated  from  the  calculation,  the  average  mortality  rate 
immediately  rises  to  between  20  and  30  per  cent.  The  latter  is  in 
keeping  with  the  figures  of  Page,  who  reports  a  mortality  rate  of  21.5 
per  cent,  for  four  London  hospitals  between  the  years  1906  and  1910. 


Primary   Mortality 


175 


During  this  same  time  sixty-nine  suprapubic  prostatectomies  were 
performed  in  St.  Thomas's  Hospital  with  a  mortaUty  rate  of  20.3  per 
cent.  Wade  gives  the  astonishing  information  that  the  mortality  rate 
in  one  of  the  largest  hospitals  of  Scotland  for  a  ten-year  period  was 
35.4  per  cent. 

Suprapubic  Prostatectomy 


Operator 


Number  of  cases 


Mortality  (per  cent.) 


Gile 

Tenney  and  Chase 

Deaver  (collected  series) 

Freyer 

Dillingham 

Watson 

Kelley 

Watkin 

Scherck 

Denslow 

Gardner 

Walker 


24 

46.0 

396 

9.8 

1734 

6.9 

1550 

5-33 

8s 

2.4 

50 

12.0 

75 

20.0 

60 

10. 0 

ISO 

8.0 

200 

6.0 

218 

4.1 

112 

S-o 

Perineal  Prostatectomy 


Operator 


Mortality  (per  cent.) 


Gile 

Deaver  (collected  series) 

Dillingham 

Watson 

KeUey 

Watkin 

Scherck 

Gardner 

Young 

Legueu  (collected  series) 

Tenney  and  Chase  (collected  series) 


10. s 

10.9 

6.6 

6.3 
10. o 

30 
20.0 
19.0 

3-77 

8.0 

7.6 


A  most  interesting  study  of  the  subject  now  under  discussion  has 
been  made  by  Whiteside,  who  in  1905  presented  a  paper  before  the  Sec- 
tion on  Genito-Urinary  Diseases  of  the  American  Medical  Association 
in  which  he  stated  that  the  average  mortahty  following  prostatectomy 
was  20  per  cent,  and  with  only  30  per  cent,  of  cures.  In  a  second  paper 
presented  ten  years  later  (1915)  before  the  same  association,  he  reviews 


176 


Prognosis 


the  work  of  thirty-four  surgeons  giving  data  on  1423  cases  including 
his  own  cases.  In  the  latter  series  about  half  of  the  surgeons  contribu- 
ting more  than  half  (820)  of  the  1423  cases  were  men  experienced  in 
either  the  suprapubic  or  the  perineal  operation.  The  primary  mor- 
tality rate  was  less  than  3  per  cent,  in  the  hands  of  these  men  while 
in  the  hands  of  the  inexperienced  it  was  26  per  cent. 

Causes  of  Primary  Mortality  Following  Prostatectomy. — The 
chief  dangers  of  the  operation  which  frequently  cause  the  immediate 
post-operative  death  of  the  patient  are  in  their  order  of  frequency  in 
our  collected  series  as  follows: 


Causes  of  death 


Number  of  cases 


Uremia 

Hemorrhage 

Shock 

Sepsis 

Cardiovascular 

Pyelitis  and  pyonephrosis. . 

Asthenia , 

Pulmonary , 

Embolus 

Diabetes 

Extravasation  of  urine 

Acute  dilatation  of  stomach 

Air  embolus 

Intestinal  paresis 

total 


39 
32 
18 

13 

10 

8 

7 
6 

5 

3 

2 
2 

I 
I 

147 


These  figures  indicate  that  69  per  cent,  of  all  deaths  following  prosta- 
tectomy are  due  either  to  uremia,  hemorrhage,  shock  or  sepsis.  The 
relative  incidence  of  the  causes  of  death,  as  given  in  the  foregoing 
tabulation,  is  contradicted  by  some  writers  in  whose  experience  sepsis 
is  the  most  frequent  cause  of  death  after  the  suprapubic  operation.  In 
almost  all  of  the  larger  series  of  collected  statistics  whether  dealing 
with  the  suprapubic  or  the  perineal  operation,  uremia  is  placed  at  the 
head  of  the  list  of  lethal  factors.  The  unusually  high  percentage  occur- 
rence of  fatal  hemorrhage  in  our  series  is  difficult  to  explain  except  on 
the  basis  of  imperfect  hemostasis,  in  other  words,  an  inexcusable  fault 
in  technique.  Freyer  does  not  mention  hemorrhage  as  a  cause  of  death 
in  any  of  the  fifty-seven  fatal  cases  among  a  series  of  1036  suprapubic 
prostatectomies  reported  in  1913. 


Causes  of  Death 

Causes  of  Death  After  Prostatectomy  (Freyer) 


177 


Causes   of   death 


Number  of  cases 


Uremia 

Heart  disease 

Shock 

Exhaustion 

Septicaemia 

Mania 

Malignant  disease  of  liver 

Bronchitis 

Pneumonia 

Heat  stroke 

Pulmonary  embolus 

Cerebral  hemorrhage 

Acute  pancreatitis 


24 
9 
7 
3 
3 
2 
2 
2 


57 


The  following  table  gives  in  their  order  of  frequency,  the  causes  of 
death  in  a  series  of  36  fatal  cases  of  suprapubic  prostatectomies  operated 
upon  in  the  Lankenau  Hospital  of  Philadelphia. 


Causes  of  Death  following  Prostatectomy  (Lankenau  Hospital,  Philadelphia) 


Causes  of  death 


Number  of  cases 


Uremia 

Pulmonary 

Shock 

Myocarditis. . . . 

Sepsis 

Asthenia 

Peritonitis 

Meningitis 

Gastro-enteritis 


36 


Tenney  and  Chase  have  given  in  the  following  tabulation  the  causes 
assigned  for  death  in  a  series  of  forty-six  fatal  cases. 


178  Prognosis 

Causes  of  Death  Following  Prostatectomy  (Tenney  and  Chase) 


Number 

of  cases 

Causes  of  death 

Within  48  hours 

Within 

12  days 

Suprapubic 

Perineal 

Suprapubic 

Perineal 

Uremia 

2 

4 
2 
0 

2 
0 

I 
0 

II 

S 
I 
0 
2 
2 
0 

2 
0 

12 

9 

4 
S 

I 
2 

I 
I 
0 

23 

9 

2 

Shock  and  hemorrhage 

Pulmonary 

I 

Sepsis 

3 
3 
2 

Cardiac 

Collapse 

Anesthesia 

2 

Unknown 

I 

Total; 

2^ 

Pauchet,  who  strongly  advocates  the  two  stage  operation,  mentions 
infection,  renal  insufficiency,  and  narcosis  as  the  prominent  causes  of 
death.  He  reports  four  series  of  one  hundred  cases  each,  with  a  mor- 
tality rate  as  follows: 

First  one  hundred  cases lo.o  per  cent. 

Second  one  hundred  cases 8.1  per  cent. 

Third  one  hundred  cases 6.5  per  cent. 

Fourth  one  hundred  cases 4.0  per  cent. 

This  progressive  improvement  Pauchet  attributes  to  improve- 
ment in  operative  technique  and  to  better  pre-operative  and  post-opera- 
tive care  of  patients.  The  two-stage  operation  finds  a  strong  champion  in 
this  writer  who  advocates  preliminary  cystostomy  from  three  weeks  to 
several  months  in  advance  of  the  prostatectomy,  according  to  the  exi- 
gencies of  the  case.  A  prominent  feature  in  the  technique  is  the  care 
with  which  opening  of  the  space  of  Retzius  is  avoided  to  prevent  pelvic 
cellulitis  which,  in  Pauchet's  opinion,  is  a  frequent  predisposing  factor  to 
fatal  infection.  The  use  of  local  anesthesia  for  both  the  perineal  and  the 
suprapubic  operations  and  section  of  the  vasa  deferentia  in  aged  patients 
to  prevent  epididymo-orchitis,  which  may  become  a  lethal  factor  after 
prostatectomy,  especially  in  debilitated  subjects,  are  other  features 
outlined  in  this  valuable  paper.  The  means  of  pre-operative  disintoxi- 
cation of  the  patient  and  of  eliminating  the  effects  of  narcosis  are 
described  in  detail. 

In  reviewing  any  series  of  fatalities  following  prostatectomy,  it  will 


End-Results  179 

be  noted  that  there  are  certain  fatal  periods,  a  fact  to  which  attention 
has  already  been  drawn  by  Tenney  and  ChasQ  whose  observations  in  a 
larger  series  of  cases  concurs,  for  the  greater  part,  with  our  own.  In 
their  series  of  73  fatal  cases  there  were  twenty-three  deaths  during  the 
first  forty-eight  hours  after  operation,  twelve  deaths  occurring  during 
the  seventh,  eighth,  and  ninth  days  after  operation;  while  the  third 
fatal  period  is  that  at  the  end  of  the  second  week  when  six  deaths 
occurred.  From  the  twentieth  to  the  twenty-second  day,  inclusive, 
there  were  seven  deaths.  Two-thirds  of  all  deaths  occurred  during 
these  fatal  periods. 

Among  the  most  distressing  and  usually  unavoidable  accidents  after 
prostatectomy  are  cerebral  embolism  and  apoplexy  which  often  cause 
the  death  of  a  convalescent  patient  already  fully  recovered  from  the 
operation  and  about  to  be  discharged  from  the  hospital.  These  acci- 
dents are  fortunately  rare.  A  not  inconsiderable  number  of  patients  die 
within  the  first  year  after  leaving  the  hospital  of  causes  that  are  directly 
or  indirectly  attributable  either  to  the  operation  or  to  the  progressive 
development  of  complications  that  existed  at  the  time  of  operation  and 
which  the  latter  failed  to  cure.  Thus  we  find  that  4.2  per  cent,  of  the 
patients  in  our  collected  series  upon  whom  perineal  prostatectomies  had 
been  done  died  within  one  year  from  the  time  of  their  discharge  from  the 
hospital  while  2.5  per  cent,  of  the  suprapubic  cases  died  during  this  same 
time  interval.  The  operation  in  these  cases  was  obviously  of  little  avail 
in  prolonging  life.  Unfortunately  we  have  no  data  regarding  the  state 
of  the  patients'  health  and  comfort  during  this  brief  post-operative 
period. 

The  late  results  of  prostatectorny  are  well  shown  and,  we  believe, 
with  comparative  accuracy  in  our  series  of  which  we  have  obtained  the 
end-results  in  372  perineal  and  in  814  suprapubic  prostatectomies, 
of  which  seventy  per  cent,  and  seventy-six  per  cent,  respectively, 
are  reported  as  completely  cured.  Seventy-eight  per  cent,  of  the 
perineal  cases  and  79.4  per  cent,  of  the  suprapubic  cases  were 
alive  and  free  from  bladder  symptoms  two  years  after  operation. 
Of  the  patients  operated  upon  in  our  clinic  seventy-two  per  cent,  are 
alive  and  well  two  or  more  years  after  operation  and  eight  per  cent,  are 
living,  but  are  not  completely  cured. 

In  a  most  instructive  and  valuable  paper,  Judd  has  given  the 
results  of  542  prostatectomies  performed  in  the  Mayo  Clinic  prior  to 
April  I,  191 1.  Of  these,  461  operations  were  performed  for  benign 
hypertrophy  of  the  prostate,  seventy-four  for  cancer,  and  seven  for  tuber- 


i8o  Prognosis 

culosis  of  this  organ.  The  series  includes  a  number  of  partial  prostatect- 
omies, and  the  results  obtained  are  excellent,  especially  in  view  of  the 
fact  that  these  operations  were  performed  in  what  must  now  be  looked 
upon  as  the  comparatively  early  days  of  prostatic  surgery. 

Sixty  per  cent,  of  the  entire  series  were  "living  and  enjoying  reason- 
ably good  health"  at  the  time  of  this  report.  Fourteen  patients  in 
this  series  returned  for  the  removal  of  vesical  calculi;  twenty-nine  died 
from  kidney  disease  before  the  end  of  the  second  post-operative  month; 
eighty-one  patients  died  after  leaving  the  hospital  and  of  these  thirty 
had  carcinoma  and  twenty  died  of  some  intercurrent  disease  not 
related  to  the  urinary  system. 

A  most  interesting  feature  of  this  report  is  the  record  of  autopsy 
findings  in  the  twenty-nine  cases  of  renal  disease  in  all  of  which  it  was 
possible  to  demonstrate  an  acute  nephritis  superimposed  on  an  old 
infection  of  the  kidneys. 

The  physical  condition  of  the  individual  is  of  major  importance, 
the  average  result  being  of  only  relative  importance  when  we  are 
called  upon  to  prognosticate  the  result  of  operation  in  a  given  case. 
However  if  the  patient  desires  statistical  information  he  can  be  assured 
that  his  chances  in  company  with  that  of  fellow  sufferers  for  recovery 
from  the  operation  are  better  than  ninety  per  cent,  and  that  the  prob- 
abilities of  continued  life  and  entire  comfort  are  better  than  seventy 
per  cent.  Seventy-two  per  cent,  of  our  own  patients  are  alive 
and  well  at  periods  ranging  from  one  year  to  twelve  years  after  the 
operation. 

Predetennining  Factors  in  the  Mortality  Rate  of  Prostatectomy.^ 
Of  the  many  factors  that  play  an  important  part  in  determining  the  mor- 
tality rate  of  prostatectomy,  age,  per  se,  has  relatively  little  influence. 
With  increasing  age  the  reserve  powers  of  the  vital  organs  naturally 
diminish  so  that  the  older  the  individual  the  less  likely  is  he  to  withstand 
the  shock  of  operation  and  the  evil  effects  of  confinement  to  bed. 
The  aged  man  therefore  remains  a  poorer  operative  risk  for  many 
reasons,  the  most  important  of  which  is  his  greater  susceptibility  to 
complications  especially  of  the  pulmonary  and  cardio-renal  types. 
The  effects  of  hemorrhage  and  infection  are  disastrous  to  the  aged 
individual  although  operative  shock  unassociated  with  hemorrhage  is 
borne  with  suprising  success  by  very  old  men.  Old  age  of  itself  is  not 
a  contra-indication  to  operation,  many  brilliant  successes  being 
obtained  with  the  operation  of  prostatectomy  in  men  between  the 
ages  of  seventy-five  and  eighty-five  years. 


Factors  in  Mortality 


i«i 


Decade  Mortality  Following  Prostatectomy 

Cases 

Ages 

Mortality, 

Decade  mortality, . 

per  cent. 

per  cent. 

8 

39-49 

0.0   1 

31 

50-54 

10. 0   \ 

5.8 

89 

55-59 

45  J 

20I 

60-64 

7.0  1 

221 

65-69 

XX.3 

95 

17s 

70-74 

13.0   I 

65 

75-79 

18.5/ 

iS-o 

24 

80-84 

8.0 

0 

85-89 

0.0 

2 

90-94 

50.0 

The  above  series  would  indicate  that  the  death  rate  steadily  increases 
with  advancing  years;  which  is  probably  the  case,  although  it  is  not 
true  in  our  personal  experience  since  37.7  per  cent,  of  our  fatalities  occur 
in  patients  between  the  ages  of  seventy  and  eighty,  while  39.6  per  cent, 
of  all  fatalities  occur  in  patients  between  the  ages  of  sixty  and  seventy 
years. 

As  a  general  rule,  the  convalescence  of  very  aged  patients  after 
prostatectomy  is  stormy  in  comparison  with  the  smoother  uncompli- 
cated recovery  of  the  younger  individual. 

The  duration  of  the  disease  is  an  important  prognostic  factor,  as  are 
also  the  type  of  pre-operative  treatment  that  the  patient  has  been  given 
and  the  local  complications,  such  as  acute  urinary  retention,  from 
which  he  has  suffered  in  the  past. 

These  factors,  however,  together  with  more  remote  influences, 
including  personal  habits,  occupation,  previous  diseases  and  the  like,  are 
of  prognostic  significance  only  in  so  far  as  they  influence  the  organs  and 
tissues  upon  the  recuperative  powers  of  which  the  recovery  of  the 
individual  depends. 

The  post-operative  complications  leading  to  fatalities  in  prostatec- 
tomy are  usually  exaggerations  of  pre-existent  disease  usually  of  the 
kidneys;  less  often  they  are  dependent  upon  technical  errors  in  operative 
technique. 

Complications  of  Prostatectomy. — In  considering  the  complica- 
tions which  lead  directly  to  a  fatal  result  following  prostatectomy  we 
will  pay  special  attention  to  the  more  common  types  and  to  those  which 
are  more  or  less  peculiar  to  this  condition. 

Pulmonary  complications,  which  stand  eighth  in  our  list  of  lethal 


i82  Prognosis 

factors  might,  at  first  thought,  be  looked  upon  as  a  more  common  com- 
plication in  these  aged  individuals.  Undoubtedly  they  are  more 
frequent  than  these  figures  indicate  but  they  are,  for  the  most  part, 
congestive  in  type,  and  with  proper  treatment  subside  promptly. 
Pulmonary  embolus  is  a  rare  cause  of  post-operative  death.  Diabetes 
which  is  given  as  the  cause  in  three  fatalities  is  a  positive  contra-  indica- 
tion to  operation  unless  the  disease  improves  markedly  under  medical 
treatment.  The  diabetic  must  be  gotten  into  the  state  where  wound 
healing  can  be  anticipated  with  reasonable  assurance  and  where  there 
is  only  a  remote  danger  of  fatal  acidosis  supervening  upon  operation. 

Cerebral  hemorrhage  cannot  always  be  prevented,  but  an  unusually 
high  blood  pressure  and  very  marked  arteriosclerosis  are  danger 
signals  that  must  be  heeded.  Acute  dilatation  of  the  stomach,  and 
intestinal  paresis  resulting  from  toxemia  are  rare  though  usually  fatal 
complications  of  prostatectomy. 

Much  difference  of  opinion  exists  among  statisticians  as  to  the 
relative  frequency  of  the  prominent  causes  of  death  following  prostatec- 
tomy. In  our  collected  series  of  cases,  renal  failure  and  hemorrhage 
are  by  far  the  most  prominent  fatal  complications  of  operation,  while 
in  our  personal  experience  fatal  bleeding  has  been  exceedingly  rare, 
indeed  practically  unknown  since  we  began  packing  the  prostatic  bed 
with  gauze  in  all  cases  where  the  hemorrhage  is  not  arrested  spontan- 
eously soon  after  the  enucleation  of  the  tumor. 

Pelvic  cellulitis  and  wound  infection  are  likewise  rare  factors  in  our 
fatal  prostatectomies.  Uremia,  pulmonary  complications  and  shock 
are  the  more  common  post-operative  complications  which  present 
themselves  to  us.  Wade,  on  the  contrary,  quoting  the  figures  of  Page, 
speaks  of  these  as  coinciding  with  his  own  and  states  that  far  and  away 
the  commonest  cause  of  death  is  septic  absorption  arising  from  wound 
infection,  and  that  renal  disease  occupies  second  place  among  the 
lethal  factors. 

The  prognosis  is  undoubtedly  influenced  by  the  presence  of  a  foul 
cystitis,  not  only  as  regards  the  primary  mortality  rate  which  is  higher 
in  this  class  of  cases  than  in  mildly  infected  ones,  but  also  in  respect  to 
the  likelihood  of  infectious  complications  such  as  pyelonephritis,  epi- 
didymitis, pelvic  cellulitis,  and  wound  infection,  or  of  embolic  involve- 
ment of  the  lungs  or  of  the  venous  system.  Frequently  associated  with 
the  infected  cases  are  vesical  calculi  which  have  long  been  supposed  to 
exert  a  favorable  influence  on  the  prognosis.  This  erroneous  belief  had 
been  handed  down  from  writer  to  writer  until,  with  the  collection  of 


Complications  183 

large  number  of  statistics  its  fallacy  became  apparent.  In  19 13  Freyer 
reported  190  cases  of  enlarged  prostate  complicated  by  calculus  with  a 
mortality  rate  of  8.42  per  cent,  as  contrasted  with  a  mortality  rate  of 
4.84  per  cent,  among  846  cases  unassociated  with  vesical  calculus. 
Freyer,  in  his  most  recent  contribution,  reports  274  cases  of  enlarged 
prostate  associated  with  stone,  with  an  operative  mortality  rate  of 
7.25  per  cent. ;  the  general  mortahty  rate  in  1550  cases  was  5.33  per  cent. 
According  to  our  figures  stone  is  found  in  9.8  per  cent,  of  cases  of  enlarged 
prostate.  In  the  belief  of  twenty-four  of  the  thirty-four  surgeons  whom 
we  consulted  in  the  matter,  the  presence  of  stone  has  no  influence 
whatsoever  in  prognosis.  According  to  Tenney  and  Chase,  who  report 
107  cases  of  prostatic  hypertrophy  compHcated  by  stone  in  the  bladder, 
the  relative  mortality  of  those  with  and  without  stone  is  as  12  to  8.6. 
These  figures  indicate  the  more  hazardous  nature  of  prostatectomy 
when  vesical  calculus  complicates  the  prostatic  disease,  especially  when 
the  prostate  and  stone  are  removed  through  the  perineum. 

The  least  serious  of  the  infectious  complications,  such  as  epididymitis, 
may  be  the  deciding  factor  in  causing  the  death  of  a  debilitated  subject. 
Every  effort  should  therefore,  be  made  both  before,  during,  and  after 
the  operation  to  minimize  the  chances  of  bacterial  growth  and  dissemi- 
nation. Epididymitis  may  occur  before  the  operation  and  especially 
after  instrumentation,  but  more  commonly  succeeds  it.  McDonald 
has  reported  forty-five  cases  of  epididymitis  among  118  patients  (27.5 
per  cent.),  fourteen  of  which  developed  it  before  operation,  twenty- 
seven  while  the  patient  was  convalescing  in  the  hospital  after  operation, 
and  four  in  which  this  complication  arose  after  the  patients  had  been 
dismissed  from  the  hospital. 

It  is  indeed  a  distressing  experience  to  have  suppurative  epididymo- 
orchitis  necessitating  orchidectomy  occur  in  a  patient  prior  to  the 
operation  of  prostatectomy  for  which  he  originally  entered  the  hospital. 
The  condition  is  usually  unilateral  although  infection  of  the  opposite 
side  may  follow  at  varying  intervals  of  time.  It  is  advisable  in  patients 
who  have  badly  infected  bladders  and  a  history  of  recurrent 
epididymitis,  to  expose  the  vasa  at  the  base  of  the  scrotum,  remove  a 
small  segment  from  each  one  and  ligate  the  ends  before  proceeding 
with  the  prostatectomy. 

Phlebitis  is  a  rare  sequel  of  the  operation  and  is  usually  not  a  serious 
one  itself,  although  it  may  necessitate  longer  confinement  of  the 
patient  to  bed  than  would  otherwise  be  necessary.  Surface  wound 
infection  is  more  commonly  met  with,  but  is  of  little  cUnical  significance 


184  Prognosis 

in  comparison  with  infection  of  the  deep  wound  of  the  prostatic  bed. 
Serious  infection  is  more  likely  to  occur  here  following  the  suprapubic 
operation,  as  are  also  its  fatal  sequelae,  pelvic  cellulitis  and  peritonitis. 
The  latter  is  sometimes  due  to  infection  which  gains  entrance  to  the 
peritoneal  cavity  through  an  incision  in  the  peritoneal  membrane  at 
the  summit  of  the  bladder;  this  must  be  carefully  pushed  away  before 
the  bladder  wall  is  incised. 

Cystitis  itself  is  an  unimportant  complication  of  the  operation, 
but  is  the  fruitful  source  of  bacteria  which  gives  rise  to  much  concern 
when  transplanted  to  other  and  more  fertile  fields. 

Among  the  more  inportant  of  the  infectious  complications  is  pyelo- 
nephritis. Pyonephrosis  when  present  has  almost  invariably  existed 
prior  to  operation.  These  two  infectious  processes  stand  sixth  in  the 
list  of  fatal  factors  after  prostatectomy.  Chronic  pyelonephritis  is  a 
common  pre-operative  complication  of  prostatic  hypertrophy  and  is  a 
prominent  cause  of  the  kidney  destruction  that  so  often  results  after 
operation  in  fatal  uremia.  This,  as  well  as  pyonephrosis  with  total 
unilateral  renal  destruction  may  easily  be  overlooked  before  operation, 
especially  in  cases  where  ureteral  catheterization  is  impossible.  How- 
ever, with  the  aid  of  the  various  kidney  functional  tests,  cromo-uretero- 
scopy  and  cysto-ureteropyelography,  etc.,  these  mistakes  are  now 
rarely  made  in  well-organized  clinics. 

Acute  post-operative  pyelonephritis  is  rarely  fatal  if  uncompli- 
cated by  pre-existent  renal  disease.  The  diagnosis  and  treatment 
of  these  conditions  will  be  discussed  in  describing  post-operative 
treatment. 

The  infectious  complications  of  prostatectomy  are,  as  we  have 
already  mentioned,  of  secondary  importance  as  fatal  factors.  Far 
more  important  in  this  respect  are  the  non-infectious  complications 
which  may  conveniently  be  divided  into  two  groups;  namely — first, 
those  dependent  solely  upon  technicalities  in  the  operation  or  the  imme- 
diate constitutional  effects  arising  from  the  operation,  and  secondly, 
those  dependent  upon  vital  functional  alterations  primarily  induced 
by  the  operation  but  contributed  to  by  pre-existent  injury  of  vital 
organs.  Prominent  among  the  former  group  are  hemorrhage  and 
shock;  of  the  latter  group,  renal  insufficiency  and  cardio- vascular 
collapse  are  of  major  importance.  A  certain  interrelation  exists 
between  these  several  conditions,  but  as  a  rule,  one  or  the  other  over- 
shadows all  the  rest  in  importance. 

Hemorrhage,  either  immediate  or  delayed,  is  a  rare  cause  of  death 


Complications  185 

following  prostatectomy  in  our  experience,  although  the  majority  of 
cases  of  fatal  shock  are  due  in  part  at  least  to  loss  of  blood. 

A  safe  practical  rule  is  to  make  sure  that  all  gross  bleeding  is  arrested 
before  the  patient  is  sent  from  the  operating  table.  In  all  doubtful 
cases  where  bleeding  continues  despite  the  usual  efforts  to  stop  it,  it  is 
our  practice  to  pack  the  prostatic  bed  with  gauze  which  is  held  in  posi- 
tion by  means  of  a  purse  string  suture  placed  around  the  margins  of 
the  prostatic  bed  on  its  vesical  side.  In  the  event  of  marked  bleeding 
occurring  soon  after  the  patient  is  sent  to  the  ward,  no  time  should  be 
lost  in  returning  him  to  the  operating  room,  re-opening  the  bladder,  and 
packing  or  repacking  the  prostatic  bed. 

Hemorrhage  may  occur  later  in  the  course  of  an  otherwise  normal 
convalescence  and  is  then  either  a  true  secondary  bleeding  which  has 
resulted  from  sloughing  in  the  prostatic  bed,  or  is  a  result  of  trauma 
incident  to  the  removal  of  the  packing.  Whiteside  reports  two  cases  of 
fatal  bleeding  due  to  the  passage  of  the  rectal  tube  several  days  after 
prostatectomy;  the  Murphy  drip  is  therefore,  he  thinks,  not  entirely 
without  danger.  Certainly  the  tube  should  be  introduced  with  great 
care  and  gentleness.  We  have  seen  bleeding  follow  the  giving  of  an 
enema.  Secondary  hemorrhage  occurs,  as  a  rule,  during  the  latter  part 
of  the  first  week  of  convalescence;  it  is  rarely  alarming.  The  blood  is 
discharged  both  by  way  of  the  suprapubic  wound  and  per  urethram. 
Only  in  the  rarest  instances  is  it  necessary  to  re-open  the  bladder  to  stop 
late  secondary  hemorrhage.  Rather  profuse  bleeding  follows  instru- 
mentation in  some  instances  as  late  as  the  fourth  week  after  operation;  it 
is  rarely  alarming  in  amount.  Every  effort  should  be  made  to  minimize 
the  amount  of  blood  lost  during  a  prostatectomy,  inasmuch  as  this 
class  of  patients  already  debilitated  by  age  and  infection  can  ill  afford 
to  lose  even  small  amounts  of  blood. 

Uremia  usually  comes  as  the  result  of  the  added  strain  incident  to 
anesthesia  and  operation  on  kidneys  already  injured.  This  is  the 
commonest  cause  of  death  after  prostatectomy  (26.5  per  cent.).  In 
some  instances  the  pre-operative  studies  have  shown  a  good  functional 
reserve  power  of  the  kidneys  notwithstanding  which  the  patient  dies  in 
uremia  following  acute  suppression  of  urine.  For  these  cases  which  are 
fortunately  rare,  there  is  little  hope  of  predetermining  the  condition  or  of 
restoring  kidney  function  once  it  has  completely  failed.  The  condition 
is  due  to  acute  congestion  of  the  renal  parenchyma  with  total  inhibition 
of  function.  By  far  the  greatest  proportion  of  post-operative  uremias 
are  dependent  upon  renal  insufficiency  which  is  caused  either  by  an 


1 86  Prognosis 

antecedent  chronic  interstitial  nephritis  or  by  infectious  pyelonephritis 
or  pyonephrosis. 

It  is  in  this  class  of  cases  and  especially  in  those  due  to  infectious 
causes  that  careful  and  often  prolonged  treatment  is  necessary  before 
operation  can  be  undertaken  with  safety.  Indeed,  no  case  of  prostatic 
hypertrophy  should  be  operated  upon  until  the  maximum  reserve 
functional  capacities  of  the  kidneys  are  determined,  and  this  can  only  be 
accomplished  through  decompression  of  the  kidneys  either  palliatively 
or  by  cystostomy. 

The  cardiovascular  complications  stand  fifth  in  the  order  of  fre- 
quency among  the  causes  assigned  for  death  in  our  collected  series  of 
cases.  Many  of  these  cases  would  have  in  all  probability  been  saved 
had  they  received  appropriate  pre-operative  treatment.  Chronic 
lesions  of  the  heart,  if  compensated  for,  need  cause  little  or  no  concern, 
although  it  is  not  always  possible  to.  detect  the  degree  of  myocardial 
degeneration  present;  acute  dilatation  of  the  heart  is  therefore  bound  to 
supervene  in  a  certain  small  percentage  of  cases.  It  is  ordinarily  a 
fatal  complication.  In  asthenic  cases  with  poor  circulatory  activity 
much  may  be  accomplished  before  operation  by  rest  and  the  use  of 
heart  tonics.  Excessively  high  blood  pressure  is  a  contra-indication 
to  operation  unless  it  is  clearly  a  compensatory  measure;  under  all  cir- 
cumstances it  must  be  taken  into  account  in  the  selection  of  the  anes- 
thetic, the  choice  of  the  method  of  operation,  and  in  the  pre-operative 
and  post-operative  care  of  the  patient. 

The  question  of  malignancy  does  not  play  a  direct  part  in  the 
primary  mortality  rate  for  the  reason  that  early  cases  of  cancer  of  the 
prostate  recover  from  operation  quite  as  well  as  the  cases  of  benign 
hypertrophy.  We  are  referring  now  to  those  cases  in  which  the  pres- 
ence of  cancer  is  not  suspected  before  operation;  indeed,  in  many 
instances,  the  presence  of  cancer  is  not  suspected  until  the  microscopic 
examination  of  the  removed  specimen  is  made.  According  to  our  sta- 
tistics, this  group  comprises  7.42  per  cent,  of  the  total,  so  that  this  factor 
has  some  prognostic  meaning. 

Morbidity  followiiig  The  Operation  of  Prostatectomy.— It  is 
extremely  difficult  to  ascertain  the  average  of  complete  cures  attained 
by  the  operation  of  prostatectomy,  but  we  believe  a  conservative 
estimate  would  fix  the  number  of  patients  who  are  not  completely 
cured  by  the  operation,  between  twenty  and  thirty  per  cent. 

The  great  majority  of  these  are  improved  however;  rarely  is  a  pa- 
tient's condition  made  worse  by  operation.     An  individual  who  has 


Postoperative  Morbidity  187 

suffered  with  complete  urinary  retention  and  has  led  a  catheter  life 
for  some  time  and  then  submits  to  an  operation  which  leaves  him  with  a 
permanent  urinary  fistula  in  the  perineum  has  certainly  not  benefited 
by  the  operation.  Much  has  been  written  about  post-operative  urinary 
fistula,  and  while  it  is  doubtless  rare,  it  is  a  not  unlikely  complication 
of  perineal  prostatectomy.  Wade,  for  instance,  has  collected  1423 
cases  of  prostatectomy  of  both  the  perineal  and  the  suprapubic  types  and 
among  these  there  were  fourteen  instances  of  fistula  (urethro-rectal) 
and  twenty-four  instances  of  complete  incontinence,  all  of  which 
followed  perineal  prostatectomy.  Young  reports  only  two  instances  of 
urethro-rectal  fistula  in  a  series  of  482  perineal  prostatectomies.  Prac- 
tically all  other  writers  agree  however  that  there  is  considerable  danger 
of  fistula  following  the  perineal  operation  and  use  this  as  an  argument 
in  favor  of  the  suprapubic  operation.  Judd  favors  the  perineal 
route  and  has  noted  but  few  fistulae  in  his  work. 

In  our  collected  series  of  cases,  fifty  (2.9  per  cent.)  cases  of  fistula 
are  reported  as  following  the  suprapubic  operation,  but  ten  of  these  are 
reported  by  a  single  individual  who  says  that  they  all  occurred  before 
the  high  incision  in  the  bladder  wall  was  adopted.  In  thirty-five 
(5.3  per  cent.)  of  656  cases,  fistulas  followed  the  perineal  operation. 
Judd  states  that  only  six  fistulae  occurred  after  373  perineal  prostatec- 
tomies, fifty  per  cent,  of  which  were  performed  for  carcinoma  of  the 
prostate  and  that  in  four  instances,  the  perineal  wound  had  completely 
closed  and  then  re-opened. 

In  the  hands  of  the  expert  prostatectomist,  a  permanent  fistula  is  a 
rare  complication  of  either  the  suprapubic  or  the  perineal  operation, 
but  even  in  the  hands  of  the  most  expert,  it  has  a  greater  incidence 
following    perineal   prostatectomy. 

In  our  series,  ten  vesico-rectal  fistulae  are  reported  as  having  followed 
the  perineal  operation. 

Incontinence  of  urine  in  the  absence  of  fistula  may  follow  both  the 
suprapubic  and  the  perineal  operation,  but  is  far  commoner  after 
perineal  prostatectomy.  True  incontinence  may  exist  prior  to  opera- 
tion, although  the  dribbling  of  prostatics  is  commonly  an  overflow  of 
retention.  True  incontinence  is  sometimes  improved  by  operation,  but 
may  be  made  worse;  at  all  events,  prostatectomy  should  never  be  under- 
taken on  a  patient  with  incontinence  until  tabes  is  ruled  out  by  a  com- 
plete neurological  examination  and  examination  of  the  spinal  fluid. 
Cystoscopic  examination  is  especially  indicated  in  this  group  of  cases. 

The  mechanism  of  bladder  control  both  normally  and  after  prosta- 


1 88  Prognosis 

tectomy  is  discussed  in  the  chapter  on  physiology  to  which  the  reader 
is  referred.  We  are  here  more  particularly  interested  in  the  frequency 
of  this  distressing  complication.  Not  one  case  of  complete  incontinence 
is  said  by  Young  to  have  occurred  in  a  series  of  331  perineal  prostatec- 
tomies, and  only  three  had  partial  incontinence.  In  our  series  of 
suprapubic  cases  this  complication  is  mentioned  forty-six  times  (2.6 
per  cent.),  but  of  these  forty  are  said  by  one  correspondent  to  have 
occurred  among  seventy-five  patients.  We  have  not  had  the  oppor- 
tunity to  verify  these  figures.  In  thirty-six  (5.1  per  cent.)  instances, 
incontinence  followed  the  perineal  operation.  The  figures  of  Whiteside 
who  reports  twenty-four  cases  of  urinary  incontinence,  all  of  which 
followed  perineal  prostatectomy,  are  given  elsewhere. 

Complete  retention  of  urine  occurred  five  times  more  frequently 
after  the  suprapubic  than  after  the  perineal  operation  in  our  series, 
of  which  latter  only  two  were  followed  by  complete  inability  to  void. 
Four  instances  of  complete  retention  followed  482  perineal  prostatec- 
tomies reported  by  Young. 

About  eight  per  cent,  of  all  patients  continue  to  show  residual  urine 
after  operation.  Frequency  of  urination  is  commonly  experienced 
after  operation,  but  this  improves  steadily  and  with  the  complete  healing 
of  the  prostatic  bed  disappears,  often  entirely.  The  presence  of  small 
amounts  of  residual  urine,  a  mild  cystitis,  or  an  interstitial  nephritis  are 
the  common  causes  of  the  nocturia  with  which  many  patients  are 
troubled  after  operation. 

Prostatism,  with  or  without  complete  retention,  following  suprapubic 
prostatectomy  is  due  usually  to  the  presence  of  tabs  of  mucosa  so  sit- 
uated as  partly,  or  completely,  to  obstruct  the  vesical  outlet;  in  perineal 
cases,  contracture  of  the  vesical  neck  commonly  explains  urinary  reten- 
tion succeeding  operation. 

The  question  of  sterility  following  prostatectomy  is  usually  unim- 
portant, but  the  surgeon  is  frequently  questioned  by  the  patient  con- 
cerning the  probable  effecj  of  the  operation  on  his  sexual  powers.  If 
loss  or  gradual  failure  of  the  latter  has  occurred,  the  patient  is  interested 
in  the  ability  of  the  operation  to  restore  his  waning  powers  to  normal. 
To  this  it  is  proper  to  answer  that  in  all  likelihood  no  improvement  will 
follow  the  operation.  In  certain  instances  however,  potency  has  been 
restored  after  the  suprapubic  operation.  This  is  difficult  to  explain 
except  on  the  grounds  that  the  relief  of  pressure  from  the  displaced 
ejaculatory  ducts  permits  the  re-establishment  of  the  normal  reflex. 

The  possibility  of  the  loss  of  sexual  power  through  the  operation  is 


Postoperative  Morbidity  189 

of  great  concern  to  many  patients,  but  this  seldom  occurs  after  the 
suprapubic  operation.  It  is  more  likely  to  follow  perineal  prostatec- 
tomy, although  preservation  of  the  ejaculatory  ducts  and  the  zone  of 
the  urethral  floor  surrounding  and  including  the  verumontanum  is 
said  to  preserve  sexual  potency.  Upon  this  belief  is  founded  the  con- 
servative perineal  prostatectomy  of  Young,  who  has  given  in  detail 
the  effects  of  perineal  prostatectomy  on  the  sexual  powers  of  351 
individuals.  Among  133  patients  whose  sexual  powers  were  about 
normal  before  operation,  seventy-eight  (59  per  cent.)  stated  that  there 
was  a  complete  return  of  sexual  powers,  while  one  hundred  (75  per  cent.) 
stated  that  erections  returned  after  operation.  In  twenty-four  cases 
(18  per  cent.)  there  was  complete  and  permanent  loss  of  sexual  power. 
This  is  a  greater  proportion  by  far  than  follows  the  suprapubic  operation. 
One  of  the  rarer  of  the  late  complications  of  prostatectomy  is  the 
occurrence  or  recurrence  of  calculi  situated  either  in  the  bladder  or  in  the 
prostatic  pouch,  or  rarely,  in  both  positions.  This  in  our  experience 
occurs  in  less  than  one  per  cent,  of  cases,  although  Judd  reports  fourteen 
instances  among  542  cases. 

REFERENCES  (CHAPTER  IX) 

Freyer:  Archiv.  Internat.  de  Chir.,  1913,  388,  vi,  4;  British  Med.  Jour.,  1919,  i,  121. 

Gardner  J.  A.:     Jour.  Amer.  Med.  Ass.,  1913,  Ixxi,  1636. 

Gile,   J.   M.:     Boston  Med.  and  Surg.  Jour.,  191 7,  clxxv,  1587. 

Harrison:  Surgical  Disorders  of  the  Urinary  Organs,  London,  1887,  471;  British  Med. 

Jour.,  1881,  I,  377;  1882,  I,  379. 
Judd:  Journal  Lancet,  1915,  xxxv,  380;  Surg.,  Gyn.  and Obst.,  i9i3,xvii,  379,  385;  Jour. 

Amer.  Med.  Ass.,  1911,  Ivii,  458. 
Lydston:  Phila.  Med.  Jour.,  1902,  x,  92. 
McDonald:  Memoirs  of  Internat.  Ass.  of  Urology,  Second  Internat.  Congress,  London, 

1911. 
McGuire:  Trans.  Am.  Surg.  Ass.,  1888,  vi,  349. 
Page:  Quoted  by  Wade,  Annals  of  Surg.,  1914,  lix,  321;  St.  Thomas  Hospital  Reports, 

1912,  xxxix,  136. 
Pauchet:  Urol,  and  Cut.  Rev.,  191 7,  xxi,  486. 
Randall,  A.,  Jour,  of  Urol.,  1917,  I,  383. 
Squier:  Surg.,  Gyn.  and  Obst.,  1913,  xvii,  433. 
Syms,  Parker:  Surg.,  Gyn.  and  Obst.,  1911,  xiii,  277. 
Tenney  and  Chase:  Jour.  Amer.  Med.  Ass.,  1906,  xlvi,  1429. 
Thompson:  Lancet,  1875,  i>  3- 
Wade:  Annals  of  Surgery,  1914,  lix,  321. 
Walker:  Lancet,  1908,  i,  1054. 
Whiteside:  Trans.  Amer.  Med.  Ass.,  Section  of  Genito-Urinary  Diseases,  1905:  J,  Am. 

Med.  Ass.,  1915,  Ixv,  1163. 
Wilson  and  McGrath:  Surg.,  Gyn.  and  Obst.,  191 1,  xiii,  647. 
Young:  Annals  of  Surgery,  1917,  Ixv,  633;  1909,!,  1232. 
Young:  Memoirs  of  Internat.  Ass.  of  Urology,  Second  Internat.  Congress,  London,  191 1. 


CHAPTER  X 

TREATMENT:  CONSTITUTIONAL;  CATHETERISM;  PREVEN- 
TION   OF    COMPLICATIONS;    AND    TREATMENT 
OF  COMPLICATIONS 

Patients  afflicted  with  enlargement  of  the  prostate  should  preserve 
their  health  by  making  everything  in  their  life  subservient  to  regularity 
and  temperance.  By  regularity  we  mean  the  avoidance  of  anything 
which  is  not  habitual ;  there  should  be  no  exceptions  to  the  amount  of  sleep, 
to  the  hours  of  meals,  to  the  daily  constitutional  walk,  to  the  hour  of 
retirement,  to  the  distance  travelled,  to  the  quantity  of  food  and  drink, 
to  the  amount  of  intellectual  labor,  or  to  anything  which  arises  in  a 
man's  life.  And  temperance  is  epexegetical  of  regularity:  not  only 
should  everything  conjoin  to  allow  the  patient  to  pursue  the  even  tenor 
of  his  way,  but  there  should  be  moderation  in  all  things;  his  habits  should 
embrace  the  happy  medium  in  which  alone  the  path  of  safety  lies. 

Such  habits  as  these  are  possible  only  for  the  man  who  is  in  easy 
circumstances.  The  day-laborer,  the  overworked  artisan,  who  knows 
not  in  the  evening  whence  will  come  the  money  to  buy  the  morrow's 
bread,  cannot,  if  he  would,  lead  a  life  of  such  orderly  quiet  as  is  enjoined 
on  his  more  fortunate  neighbor.  And  it  is  only  where  this  life  can  be 
led  that  the  purely  palliative  treatment  can  be  expected  to  render  the 
patient  comfortable.  Where  it  cannot  be  pursued,  radical  treatment  is 
urgently  demanded  to  restore  the  individual  to  his  former  condition  of 
independence. 

I .  Constitutional  Treatment,  (a)  Hygienic  Treatment. — Regularity 
and  temperance  being  our  watchwords,  they  are  to  be  applied  to  every 
aspect  of  the  individual's  life.  If  possible,  suitable  climatic  conditions 
should  be  obtained,  the  cold  winters  of  the  north  being  avoided  by  so- 
journs in  lower  latitudes.  The  patient's  clothing  should  be  warm 
enough  to  avoid  chilling  at  all  seasons  of  the  year.  Flannel  in  cold 
weather,  and  silk  in  hot  weather,  should  be  worn  next  the  skin.  Espe- 
cially important  is  the  avoidance  of  wet  feet.  Waterproof  shoes  should 
be  worn,  or  sandals  of  rubber  should  be  constantly  carried  in  the  over- 
coat pocket,  ready  for  use  in  any  emergency.  Of  more  value  even  than 
these  precautions,  oftentimes,  is  the  invariable  rule  to  change  the  shoes 

190 


Constitutional  Treatment  191 

and  stockings  immediately  upon  the  return  from  being  caught  in  any 
dampness,  no  matter  how  trivial  it  may  appear.  Even  if  the  feet  do 
not  feel  wet,  it  is  a  safe  precaution  to  change  the  shoes  and  stockings  as  a 
matter  of  habit.  A  very  slight  ischemia  of  the  cutaneous  circulation 
may  bring  on  alarming  prostatic,  vesical,  and  renal  congestion,  with 
retention  of  urine  and  even  uremic  symptoms  in  a  very  short  space  of 
time;  and  of  no  conditions  than  these  is  it  more  true  that  an  ounce  of 
prevention  is  worth  pounds  of  cure.  It  is  less  dangerous  to  become 
overheated  than  to  be  chilled,  provided  chilling  is  not  the  consequence 
of  becoming  overheated.  To  perspire  freely  is  good  for  these  patients; 
and  for  the  purpose  of  aiding  the  excretory  action  of  the  skin  regular 
bathing  should  be  enjoined,  provided  it  can  be  done  in  a  well-heated  and 
ventilated  bath-room.  It  will  be  found  safer  with  patients  of  advanced 
age  to  depend  on  moderate  sweating,  followed  by  a  carefully  adminis- 
tered sponge  bath,  or  even  on  merely  rubbing  the  skin  dry,  where  an 
attendant  cannot  be  provided  for  bathing,  than  to  risk  exposure  in  a 
poorly  appointed  bath-room.  The  water  should  be  warm;  if  kidney 
disease  is  present  hot  baths  are  a  valuable  adjuvant  in  securing  proper 
excretion  of  the  waste  products.     Cold  baths  are  to  be  condemned. 

Hot  sitz  baths  immediately  before  retiring  are  very  grateful  in  some 
cases. 

The  bowels  should  be  regularly  opened  at  least  once  each  day; 
and  even  if  they  act  normally,  the  use  of  a  brisk  saline  cathartic  is  to 
be  enjoined  at  least  once  a  month.  Straining  in  defecation  causes 
general  pelvic  congestion,  and  this  reacts  unfavorably  on  the  prostate. 

The  urine  is  never  to  be  retained  beyond  the  accustomed  period  of 
three  or  four  hours  during  the  day.  Holding  it  longer  will  be  very  apt 
to  render  the  patient  unable  to  evacuate  it  when  be  finally  makes  the 
attempt.  The  bladder  is  to  be  scrupulously  evacuated  as  the  last  thing 
just  before  getting  into  bed.  If  the  patient  is  forced  to  urinate  during 
the  night,  it  is  better  for  him  to  use  a  urinal  without  leaving  his  bed, 
and  thus  avoid  exposure  and  unnecessary  exertion.  Of  course,  where 
the  patient  is  unable  to  make  his  water  in  the  supine  position,  he  will 
usually  have  to  leave  his  bed  entirely  for  this  purpose.  Socin  and 
Burckhardt  condemn  the  practice  of  urinating  in  the  supine  position, 
stating  that  the  extra  straining  thus  necessitated  predisposes  to  atony 
of  the  bladder.  The  patient  may  try,  at  all  times  of  the  day,  to  urinate 
in  the  knee-chest  position,  so  as,  if  possible,  to  overcome  the  retro- 
prostatic  pouch  by  the  aid  of  gravity. 

The  patient  should,  on  the  other  hand,  be  discouraged  from  passing 


192  Constitutional 

his  urine  unnecessarily  often.  With  a  bladder  not  markedly  diseased 
it  should  seldom  be  imperative  to  evacuate  less  .than  180  or  240  cc.  of 
urine  at  a  time. 

Six  to  eight  hours  is  enough  for  a  patient  to  spend  in  bed  at  night. 
If  more  sleep  is  required,  a  nap  may  be  taken  in  the  daytime.  He 
should  not  sleep  long  in  the  same  position,  changing  after  an  hour  or 
so  from  the  back  to  one  side,  and  again  to  the  other,  so  as  to  avoid 
congestion  of  the  vesical  neck  and  prostate.  Where  exercise  cannot 
be  taken,  massage  is  an  invaluable  substitute. 

His  daily  occupation  should  be  such  as  does  not  require  exertion 
either  constantly  in  mild  degree  or  occasionally  to  excess.  It 
should  not  interfere  with  his  meal  hours,  nor  by  causing  mental  worry 
or  fatigue  interfere  with  his  repose  at  night.  He  should  "go  softly  all 
his  days. " 

(b)  Dietetic  Treatment. — Certain  articles  of  diet  are  notoriously 
unwholesome  even  for  the  healthy  man,  but  in  addition  to  eschewing 
these,  the  prostatic  should  likewise  avoid  certain  edibles  usually  re- 
garded as  harmless.  Vegetables  of  all  kinds  are  permissible,  and 
meats  in  moderation.  The  frequent  association  of  kidney  disease 
makes  poultry  a  more  suitable  animal  food  than  butcher's  meat.  Of 
this  latter  food,  especially  to  be  avoided  are  pork,  ham,  sausage,  veal, 
and  to  a  less  degree  beef.  Stewed  sweetbreads,  boiled  fish,  stewed  or 
raw  oysters,  are  wholesome  articles,  and  may  largely  replace  meat. 
Clams  and  crabs  are  very  unsuitable.  Eggs  and  cheese  are  to  be 
partaken  of  with  caution. 

Potatoes  should  be  taken  sparingly;  green  vegetables,  provided 
they  do  not  upset  the  stomach,  are  to  be  allowed  liberally,  as  they 
tend  to  keep  the  stools  soluble.  Spinach,  cauliflower,  asparagus, 
stewed  celery,  squash  (marrow  vegetable),  and  similar  vegetables  are 
the  best.  Tomatoes,  peas,  and  beans  are  to  be  allowed  only  occasion- 
ally, and  in  great  moderation.  Corn  is  not  to  be  taken  at  all.  For 
solid  food  nothing  is  as  suitable  as  well-boiled  rice.  Cereals  of  all  kinds 
may  be  given,  especially  barley;  also  wheaten  and  rye  bread,  but  never 
hot,  nor  in  any  amount  when  fresh. 

Salads  and  highly  seasoned  gravies  and  sauces  are  to  be  avoided, 
although  lettuce  or  even  fresh  celery,  with  French  dressing,  may  be 
occasionally  indulged  in. 

Of  fruits,  the  most  suitable  are  prunes,  rhubarb  especially  when 
stewed  without  much  sugar;  grapes,  oranges,  lemons,  pears,  and  apples, 
in  moderate  quantities  may  serve  occasionally  to  vary  the  monotony. 


Diet  193 

Figs,  bananas,  peaches,  blackberries,  strawberries,  and  raspberries  are 
harmful  in  the  order  named. 

Almost  any  kind  of  milk  dessert  is  permissible,  including  tapioca, 
sago,  rice  and  bread  puddings,  as  well  as  ice-cream. 

Great  abundance  of  fluid  should  be  taken,  except,  of  course,  where, 
from  renal  complications,  polyuria  is  the  most  distressing  symptom. 
Water  is,  of  course,  the  most  valuable  beverage,  and  the  most  con- 
stantly palatable;  and  is  probably  of  quite  as  much  value  uncarbonated 
and  in  its  natural  state.  But  the  various  alkaline  waters  may  do  good 
where  the  urine  is  acid  and  the  diathesis  gouty.  The  drinking  of  milk 
is  to  be  especially  encouraged.  Alcoholic  beverages  are  best  avoided 
altogether;  but  here,  as  elsewhere,  we  think  that  long-continued  habits 
should  not  be  rudely  disturbed,  and  prefer  to  allow  our  elderly  patients 
to  continue  the  very  moderate  use  of  whiskey  with  their  meals,  as 
in  such  quantities,  and  for  such  patients,  it  acts  as  an  undeniable  aid  to 
digestion.  Whiskey  when  good,  is  probably,  the  least  harmful  form  in 
which  these  patients  can  take  alcohol;  the  light  Rhine  wines  also.  Hock, 
Moselle,  and  others,  may  be  taken,  but  Port  and  Madeira  are  to  be 
studiously  avoided.  Claret  may  be  allowed  in  moderation.  An  excess 
of  sugar  throws  hard  work  on  the  kidneys  and  the  bladder,  and  predis- 
poses to  urinary  fermentation.  Tea  is  better  than  coffee,  and  coffee 
than  chocolate;  but  none  of  these  beverages  should  be  taken  more  than 
once  a  day,  and  then  in  the  morning,  and  with  a  liberal  dilution  of  milk 
or  cream. 

•Food  should  not  be  partaken  of  late  at  night;  if  possible,  dinner 
should  be  the  midday  meal.  No  fluid  should  be  taken  during  the  even- 
ing nor  on  retiring  for  the  night.  Patients  often  find  themselves  able  to 
sleep  the  night  through  without  urinating  if  this  rule  is  observed.  Yet 
in  some  gouty  patients  where  the  urine  is  much  concentrated,  a  glass  of 
water  drunk  just  at  bed-time  will,  as  remarked  by  Moullin,  by  diluting 
the  urine  and  rendering  it  less  irritating,  have  the  same  effect. 

(c)  Drugs. — Very  few  drugs  are  of  any  permanent  service  in 
enlargement  of  the  prostate.  Tonics  are  usually  indicated  for  the 
general  health;  and  of  these  we  would  recommend  the  time-honored 
combination  of  the  tincture  of  nux  vomica,  with  dilute  hydrochloric  acid 
and  some  simple  bitter,  such  as  the  compound  infusion  of  gentian,  as 
being  as  suitable  as  any  other  prescription.  Strychnine  itself  does  not 
seem  always  to  have  the  same  happy  effect  on  the  stomach  that  the 
tincture  of  nux  has,  and  unless  the  heart  demands  training  we  i^sually 
prefer  the  tincture.  • 

13 


194  Constitutional  Treatment 

As  already  mentioned,  an  occasional  cathartic  is  useful  in  every 
case;  but  many  patients  are  habitually  constipated,  and  must,  even 
in  addition  to  a  diet  carefully  selected  for  this  purpose,  take  a  laxative 
almost  constantly.  For  this  purpose  we  are  in  the  habit  of  employing 
either  pills  of  aloin,  belladonna,  and  strychnine,  or,  preferably,  if 
the  patient  will  take  it,  the  fluid  extract  of  cascara  sagrada  (Rhamnus 
Purshiana,  U.  S.  P.)-  These  remedies  should  be  commenced  in  active 
doses,  and  the  amount  taken  reduced,  as  soon  as  may  be,  to  the  least 
possible  required  to  produce  the  desired  effect.  Some  patients  can 
keep  their  bowels  happily  regulated  by  chewing  senna  leaves  or  rhubarb 
root,  of  which  they  become  almost  fond  in  time.  Compound  licorice 
powder  is  another  favorite  remedy  with  some.  Enemata  of  cold 
water  may  be  useful  in  stimulating  the  lower  bowel  and  in  decreasing 
the  pelvic  congestion.  Iodoform  or  glycerine  suppositories  may  be 
employed  in  preference  to  injections;  or  ichthyol,  locally,  or  by  mouth, 
ten  drops  in  a  capsule  three  times  daily.  The  patient  will  usually 
learn  what  form  of  medication  suits  him  best,  and  will  after  experiencing 
a  few  times  the  discomforts  of  constipation  and  hemorrhoids,  be  very 
eager  to  avoid  their  recurrence,  by  properly  regulating  his  diet  and 
medicines. 

The  tone  of  the  bladder  is  best  maintained  by  preventing  overdis- 
tention.  Atropine  should  never  be  given  long  at  a  time;  hence  the 
preference  expressed  above  for  cascara  sagrada  over  the  use  of  A.  B.  & 
S.  pills.  Strychnine  in  one  form  or  another  is  about  the  only  drug  which 
seems  to  have  any  influence  on  the  contractihty  of  the  bladder;  and  as 
in  the  form  of  the  tincture  of  nux  vomica  it  acts  favorably  on  the 
stomach,  the  intestines,  the  bladder,  and  also  the  heart,  is  probably  the 
most  useful  single  drug  we  have.  Its  prolonged  use,  however,  is  injuri- 
ous, patients  becoming  nervous  and  fidgety  when  it  is  persisted  in.  The 
dose  should  not,  as  a  tonic,  exceed  one  and  a-half  mg.  three  times  a 
day;  usually  one  mg.  is  sufficient,  except,  of  course,  where  stimulation 
is  required. 

For  the  heart,  besides  strychnine,  as  recommended  above,  an  occa- 
sional course  of  digitalis  will  be  found  beneficial.  This  drug  also 
increases  the  amount  of  urine  excreted  by  increasing  the  forward  pressure 
in  the  kidneys,  and  to  flush  these  organs  out  it  is  at  times  an  invaluable 
remedy.  It  should  never  be  continued  long,  both  on  account  of  its 
cumulative  action  and  the  danger  which  always  exists  of  exciting  an 
intractable  gastritis.  The  kidneys  are  best  controlled  by  diet,  no 
drug  being  of  any  lasting  benefit. 


Catheterism  loc 

For  the  prostate  itself  there  is  no  specific.  We  are,  however,  firm 
believers  in  the  occasional  value  of  ergot.  During  an  accession  of 
prostatic  and  vesical  congestion,  often  accompanied  by  an  attack  of 
piles,  and  with  retention  of  urine,  there  are  few  prescriptions  which 
afford  the  patient  such  comfort  after  the  urine  has  been  evacuated  by 
catheter,  as  the  following: 

1$.     Ext.  Rhamni  Purshian.  Fl 15  cc. 

Ext.  Ergotae  Fl 39  cc. 

Ext.  Hamamelis  Fl 45  cc. 

M.  S. — Teaspoonful  three  or  four  times  daily,  in  water. 

For  the  urine  there  are  many  drugs.  It  is  readily  diluted  by  increas- 
ing the  amount  of  fluid,  especially  water  and  milk,  ingested;  and  may  be 
concentrated  by  withholding  fluid  and  promoting  perspiration.  Boric 
or  benzoic  acid  will  be  found  useful  for  alkaline  urines,  and  may  be 
given  separately  or  combined,  about  300  mg.  of  benzoic  acid  being 
prescribed  with  double  the  quantity  of  sodium  borate,  to  insure 
solution.  Salol  is  an  excellent  urinary  antiseptic,  and  with  boric  acid, 
may  be  employed  for  considerable  periods — several  weeks  at  a  time — 
without  producing  injurious  effects.  Sodium  benzoate  is  another 
good  drug;  urotropin,  however,  we  prefer,  when  given  with  acid  sodium 
phosphate.  With  piperazine  we  have  little  experience,  and  seldom 
employ  it  or  the  more  irritating  drugs,  such  as  uva  ursi,  cubebs,  buchu, 
and  copaiba.  For  excessively  acid  urine  the  best  remedies  are  a  change 
in  diet,  especially  a  reduction  in  the  amount  of  sugar,  and  dilution  by 
an  increase  in  the  ingested  fluid.  The  neutral  or  alkaline  salts  of 
potassium  and  sodium  will  usually  be  found  to  aid  the  change  in 
reaction.  The  official  solution  of  potassium  citrate  may  be  freely 
taken;  and  the  alkaline  mineral  waters  and  purges  may  be  advised. 

2.  Catheterism. — It  is  seldom  justifiable  to  advise  a  trial  of  catheter 
life,  or  catheterism,  as  it  is  called. 

This  procedure  shortens  life  by  promoting  infection  of  the  bladder 
and  kidneys  and  it  should  be  advised  only  in  inoperable  cases. 

As  a  means  of  preparing  patients  for  operation  the  catheter  is  a 
valuable  instrument;  to  prescribe  its  daily  use  as  a  substitute  for  opera- 
tion is  similar  in  principle  to  the  administration  of  morphine  in  inoper- 
able cases  of  carcinoma — it  relieves  the  patient's  suffering  for  a  time 
but  eventually  fails  to  bring  relief  and  almost  inevitably  shortens  his 
life. 

Certain  individuals  show  little  susceptibility  to  infection  of  the 


196  Constitutional  Treatment 

urinary  system,  or  having  become  infected,  show  surprising  tolerance 
for  the  bacteria  and  their  products. 

These  individuals  not  infrequently  lead  catheter  lives  for  many 
years  with  little  apparent  harm.  They,  however,  are  exceptions  to  the 
general  rule  that  death  soon  follows  the  institution  of  catheterism — 
about  three  years  after,  on  the  average. 

Catheterism  will  cure  no  patients.  Some  individuals  may  have 
their  symptom  relieved,  and  be  able  to  dispense  with  the  catheter 
in  the  course  of  a  few  weeks;  but  such  cases  are  probably  those  where 
the  onset  of  the  symptoms  was  due  largely,  if  not  entirely,  to  congestion 
of  the  prostate  and  its  surrounding  structures,  and  not  to  permanent 
obstruction  from  enlargement. 


Fig.  59. — SoFT-RtJBBER  Catheter  (N£laton).    Natural  Size  of  No.  21  Of  the  French 

Scale. 

But  before  entering  upon  the  subject  of  catheterism  in  detail  it 
will  be  convenient  first  to  discuss  the  different  varieties  of  catheters  to 
be  employed,  and  then  their  sterilization  and  preservation. 

(a)  Catheters. — Catheters  are  divided  by  systematic  writers  into 
the  flexible,  the  semi-flexible,  and  the  inflexible,  of  which  four  types, 
the  Nelaton  or  soft-rubber  catheter,  the  French  coude  or  bi-coude 
woven  Qatheters,  English  or  webbed  catheter,  and  the  metallic 
catheter,  are  good  representatives.  The  English  catheter  has  the 
advantage  that  it  can  be  worked  into  any  shape  giving  a  long  prostatic 
curve  and  to  suit  the  particular  case.  This  instrument  in  our  hands  is 
more  satisfactory  than  is  the  metal  prostatic  catheter. 

The  soft-rubber  catheter,  known  by  Nekton's  name,  should  for  the 
purposes  of  prostatic  surgery  be  35  to  40  cm.  long  at  the  least. 
Its  tip  should  be  solid  beyond  the  eye,  and  the  eye  should  be 
moulded  in  the  manufacture  of  the  instrument,  and  not  cut  afterwards. 
By  having  the  tip  solid  there  is  no  space  for  the  collection  of  filth,  to 
act  as  a  ready  culture-medium  for  germs,  and  by  having  the  eye 
moulded,  not  cut,  there  is  the  assurance  that  its  edges  will  be  smooth 


Catheters  197 

and  well  turned,  so  that  by  no  possibihty  can  the  urethra  be  damaged. 
The  catheter  employed  should  be  new;  and  as  soon  as  one  commences 
to  grow  old  it  should  be  discarded.  There  is  great  danger  of  old  rubber 
breaking  and  of  leaving  a  portion  of  the  catheter  in  the  urethra  or 
bladder,  if  it  becomes  brittle;  and  when  it  has  become  fhmsy  and 
collapsed  it  is  exceedingly  difficult  to  introduce. 

The  English  catheter  is  made  of  webbing,  covered  with  shellac, 
which  renders  its  surface  smooth,  and  gives  a  certain  degree  of  rigidity 
to  the  instrument.  These  catheters  are  provided  with  stylets.  Cheap 
English  catheters  are  not  worth  buying:  they  are  thin  walled,  break 
easily,  or  at  least  become  creased,  even  when  in  the  urethra,  and  are 
sometimes  perforated  by  the  stylet  when  in  use.  The  tip  of  an  English 
catheter  is  hollow  Kke  the  rest  of  the  shaft,  and  contains  the  end  of  the 
stylet.  If  the  tip  were  solid,  there  would  be  constant  danger  of  the  stylet 
protruding  at  the  eye,  and  thus  lacerating  the  urethra.  These  catheters 
are  of  such  consistency  that  when  placed  in  hot  or  even  moderately 
warm  water  they  become  limp,  and  can  be  readily  moulded  to  any  desired 
curve;  and  by  the  action  of  cold  water  they  again  become  quite  rigid, 
and  will  retain  their  form  long  enough  for  use.  When  not  in  use,  they 
are  kept  on  the  stylet,  which  should  be  of  the  curve  desired.  As  a 
rule,  they  are  used  without  the  stylet,  but  this  may  be  allowed  to  remain 
in  place  if  more  firmness  is  required.  When  the  curve  requires  to  be 
altered  during  use,  this  is  readily  accomphshed  by  partially  with- 
drawing the  stylet,  as  will  be  more  fully  described  on  a  subsequent 
page. 

The  elbowed  (coude)  catheter  of  Mercier  is  a  very  valuable  instru- 
ment made  of  much  the  same  material  as  the  English  catheter.  Unlike 
the  latter,  however,  the  instrument  of  Mercier  should  have  its  tip 
soHd;  the  beak  is  about  eighteen  mm.  in  length,  and  is  set  at  an  angle  of 
no  degrees  with  the  shaft,  which  is  straight,  the  eye  being  in  the 
flexure  between  the  two;  or  there  may  be  one  eye  on  each  side  of  the 
beak.  It  is  important  to  purchase  only  catheters  of  this  variety  where 
the  angle  is  produced  in  the  process  of  weaving,  and  to  avoid  those 
catheters,  of  which  there  are  many  in  the  shops,  which  have  been  woven 
straight,  and  which  have  had  the  end  subsequently  turned  up.  This 
latter  variety  is  cheaper,  but  the  elbow  seldom  is  sufficiently  pro- 
nounced when  new,  and  very  soon  disappears  altogether  by  the  catheter 
resuming  its  original  hnear  form.  The  catheter  employed  by  Leroy 
d'Etiolles  had  a  longer  elbow,  which  was  set  at  an  angle  of  130  degrees 
with  the  shaft. 


198 


Catheterism 


The  double-elbowed  {bi-coude)  catheter  as  its  name  implies,  is,  one 
where  the  terminal  portion  has  a  second  angle  about  thirty-eight  mm. 
back  of  the  first.  It  is  made  of  the  same  material  as  that  with  the 
single  elbow,  but  the  second  angle  is  not  so  abrupt  as  the  first.     Where 


I 


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to   8 

2  S 


O     3 
O 


til 


the  tip  of  the  single-elbowed  catheter  is  hollow  it  may  be  passed  with  a 
stylet  of  similar  form,  when  by  partially  withdrawing  the  stylet  a  second 
elbow  will  be  produced  at  any  desired  situation  (Guyon).  There  is 
little  risk  of  the  stylet  protruding  at  the  eye  in  its  passage,  as  will  be 
seen  by  practising  these  maneuvers  before  introducing  the  catheter. 


Catheters 


199 


All  catheters  made  of  webbing  should  have  the  eye  woven  in  the 
making;  to  have  it  cut  subsequently  leaves  a  sharp  and  oftentimes 
ragged  or  ravelling  edge. 


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It  is  convenient  in  these,  as  well  as  in  curved  metallic  urethral  instru- 
ments, to  have  some  indicator  on  the  handle  to  show  which  way  the 
beak  is  pointing.  So  far  as  we  know,  there  is  at  present  no  better  way 
provided  of  determining  this  point,  in  the  case  of  the  Mercier  catheter, 
than  by  recollecting  the  relation  to  the  beak  borne  by  the  printing  on 


200  Catheterism 

the  shaft.  With  the  English  catheter  a  similar  precaution  may  be 
employed,  except  when  it  is  used  with  the  stylet,  when  the  ring-like 
extremity  of  this  guide  will  indicate  the  direction  of  the  curve. 

Metallic  catheters  usually  have  a  curved  beak.  The  original 
Mercier  catheter  was  silver,  but,  as  already  mentioned,  it  is  now  usu- 
ally made  of  webbing.  The  normal  curve  of  the  subpubic  urethra  is 
that  of  the  circumference  of  a  circle  whose  diameter  is  90  mm.;  and  the 
length  of  curve  is  the  arc  subtended  by  a  chord  of  70  mm.  but  the  curve 
of  the  catheter  is  usually  subtended  by  a  chord  of  only  55mm.  (Van 
Buren  and  Keyes.) 

In  the  urethra  altered  by  prostatic  enlargement,  however,  the  curve 
is  considerably  increased,  having  both  a  greater  diameter  and  a  greater 
length  of  arc;  so  that  various  metallic  catheters  with  "prostatic  curves" 
are  found  on  the  market.  Probably  the  largest  required  curve  is  one 
which  is  one-third  of  a  circle  whose  diameter  is  twelve  and  a  half  cm. 
It  is  important  not  only  to  have  the  curve  thus  larger,  but  for  the  curve 
to  be  greater  at  the  tip  than  elsewhere,  thus  approaching  the  instrument 
of  Mercier  in  type.  At  the  very  least,  the  curve  should  be  continued 
to  the  very  end  of  the  catheter. 

The  tip  of  metallic  catheters  should  be  solid,  to  allow  no  nidus  of  infec- 
tion to  exist,  and  it  is  even  more  indispensable  here  than  in  the  case  of 
the  webbed  catheters  for  the  eye  to  be  made  in  the  mould,  and  not  to 
be  subsequently  cut  out  by  a  punch.  The  shaft  should  be  at  least  twenty 
cm.  in  length  beyond  the  beginning  of  the  curved  beak,  since  with  an 
instrument  of  customary  length  the  bladder  might  not  be  reached. 

Metallic  catheters  should  be  plated  with  nickel,  silver,  or  some 
other  non-corrodible  metal;  and  should  be  provided  with  two  eyelets 
at  the  handle,  to  serve  as  indicators  of  the  direction  in  which  the  beak 
is  pointing.  Or  the  catheter  may  be  S-shaped,  the  opposite  direction 
of  the  two  curves  effectually  indicating  the  position  of  the  beak. 

In  all  these  catheters  for  use  in  prostatics  the  eye  should  be  amply 
large,  and  should  be  placed  in  the  concavity  of  the  curve;  or  one  eye 
may  be  placed  on  each  side,  at  different  levels,  but  from  ten  to  twenty- 
five  mm.  from  the  end.  It  is  also  best  to  use  an  instrument  of  as  large 
a  calibre  as  the  urethra  will  conveniently  take,  since  there  is  thus  less 
danger  of  entering  or  of  producing  false  passages,  and  a  better  chance 
exists  of  evacuating  pus  or  blood  clots  from  the  bladder, 

(b)  Sterilization  of  Catheters. — Soft-rubber  catheters  may  be 
boiled.  If  they  are  stewed,  the  elasticity  and  tone  is  lost  very  soon; 
but  if  the  water  is  brought  to  the  boiling  point  before  the  catheter 


Catheters  201 

is  placed  in  it,  the  rubber  will  stand  repeated  boilings  of  from  three 
to  five  minutes  without  showing  material  degeneration.  Where  boiUng 
cannot  be  employed,  as  is  the  case  under  some  circumstances  with 
rubber  catheters,  and  with  all  catheters  made  of  webbing  and  coated 
with  shellac,  chemical  disinfection  must  be  used.  Carbolic  acid,  in  the 
strength  of  one  part  to  twenty  of  water,  has  been  much  relied  upon,  the 
catheters  soaking  in  such  a  solution  for  twenty  or  thirty  minutes.  This 
substance  has  the  disadvantage,  however,  of  rendering  the  catheters 
so  flimsy,  even  when  the  solution  is  cold,  as  to  make  them 
very  difficult  to  use;  so  that  latterly  we  prefer  a  10  per  cent,  solution 
of  formalin,  which  is  itself  a  40  per  cent,  solution  of  formaldehyde 
gas  in  water.  The  well-known  hardening  effect  of  formalin  preserves 
the  desired  form  of  these  catheters  admirably.  Some  surgeons  have 
found  the  use  of  formalin  so  irritating  to  the  mucous  membrane  of  the 
urethra  as  to  cause  great  pain  to  the  patient,  as  well  as  at  times  to 
produce  a  rather  severe  urethritis.  We  have  not  however,  seen 
any  such  effects.  Wolff  advises  the  use  of  a  one  per  cent,  solu- 
tion of  corrosive  subHmate  in  equal  parts  of  glycerine  and  water, 
the  catheters  being  germ-free  at  the  end  of  six  hours.  This  solution  is 
claimed  to  possess  the  threefold  merit  of  sterilizing  the  catheters,  pre- 
serving their  elasticity,  and  rendering  them  ready  for  instant  use  with- 
out the  intervention  of  any  other  lubricant. 

Metallic  catheters  are  readily  sterihzed  by  boiling.  The  prac- 
tice of  merely  igniting  alcohol  which  adheres  to  their  surface  is  by  no 
means  sure  as  a  disinfectant,  unless  the  catheter  is  already  of  more 
than  ordinary  cleanliness.  Where  catheters  are  religiously  cleaned 
and  boiled  after  each  time  they  are  used,  this  method  will  serve  very 
well  as  a  rapid  and  efficient  manner  of  sterilization;  but  if  the  catheter 
has  been  put  away  with  septic  blood  clots  or  inspissated  pus  in  its 
interior,  it  is  idle  to  expect  the  momentary  application  of  a  flame  to 
its  surface  to  render  infection  impossible. 

All  catheters  should  be  subjected  to  the  ordinary  rules  of  sur- 
gical cleanliness  immediately  after  being  used.  After  being  washed 
clean  in  soap  and  hot  water,  and  their  cavities  thoroughly  syringed  out, 
and  emptied  if  need  be  of  clots,  etc.,  by  means  of  absorbent  cotton 
mounted  on  a  stylet,  they  should  be  returned  to  the  antiseptic  solution; 
or  if  there  will  be  no  need  for  their  use  soon  again,  they  may  be  wrapped 
in  a  sterile  towel,  after  being  shaken  dry  in  the  air. 

Rubber  preserves  its  elasticity  better  when  kept  wet,  and  it  should 
never  be  laid  away  in  a  dry  warm  place. 


202 


Catheterism 


Various  types  of  formalin  vapor  sterilizers  may  be  purchased 
from  the  instrument  makers,  but  personally  we  have  but  little  faith 
in  the  ability  of  formalin  vapor  to  sterilize  instruments,  and  much 
prefer  to  immerse  them  in  a  solution  of  formalin  or  of  carbolic  acid. 


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This  applies  only  to  such  instruments  as  will  not  stand  boiling.  In 
fact,  if  certain  precautions  are  taken,  the  best  grade  of  modern  French 
woven  catheters  may  be  boiled  without  damage  to  them.  These  in- 
struments are  coated  with  varnish  which  softens  when  they  are  boiled 
but  becomes  hard  again  when  the  instrument  is  immersed  in  cold  water. 


Catheters 


203 


Nothing  must  be  permitted  to  touch  the  instrument  when  it  is  heated 
and  it  must  lie  perfectly  straight  in  the  sterilizer  and  no  part  of  it  should 
come  into  contact  with  any  other  object.  Bending  or  grasping  the 
heated  catheter  with  a  pair  of  forceps  usually  mean  the  end  of  use- 
fulness of  that  catheter. 

Where  the  patient  has  to  catheterize  himself,  and  must  care 
•for  his  catheters  in  person,  it  is  expedient  to  render  his  necessary 
manipulations  as  simple  as  possible.  Moullin  recommends  that  he 
keep  in  his  wardrobe,   or  wherever  else  may  be  most  convenient, 


Fig.  63. — Aseptic  Pocket-case  for  Catheter.    Natural  Size. 


two  glass  cases,  long  enough  to  contain  the  catheters  without 
bending  them;  one  case  should  hold  a  small  piece  of  absorbent  cotton 
moistened  with  formalin,  and  the  other  should  be  filled  with  boric  acid 
solution,  which  should  be  changed  every  day.  A  douche  bag  filled  with 
a  strong  solution  of  green  soap  should  also  be  provided.  The  catheters, 
which  should  at  least  equal  in  number  the  number  of  times  during 
twenty-four  hours  that  the  patient  must  catheterize  himself,  and  which 
are  of  course  flexible  or  semiflexible,  should  be  rinsed  through  thoroughly 
with  the  soap  solution  and  hot  water  immediately  after  use,  and  then 
be  placed  in  the  boric  acid  solution.  Once  each  day,  or  oftener,  all 
the  catheters  should  be  boiled,  and  then  stored  in  the  formalin  case 


204  Catheterism 

until  ready  for  use.  It  appears  to  us  that  this  is  rather  a  complicated 
process  of  sterilization  for  the  average  prostatic;  and  we  would  at  any 
rate  suggest  that  after  use  and  cleansing  with  the  soap  and  water, 
the  catheter  should  be  placed  in  the  formalin  jar,  and  remain  there 
for  six  hours  at  the  least.  It  may  then  be  transferred  to  the  boric 
acid  solution  for  some  time  before  use,  and  thus  will  have  been  ster- 
ilized by  the  formalin,  and  will  have  had  the  irritating  qualities  of  this 
antiseptic  removed,  before  being  brought  into  contact  with  the  urethra. 
By  this  plan  also  the  necessity  of  boiling  is  avoided,  and  however 
useful  this  may  be  for  metallic  and  india-rubber  instruments,  we  cannot 
but  think  it  destructive  to  those  constructed  of  webbing  and  covered 
with  shellac  when  oft-repeated  sterilization  by  an  inexperienced 
individual  is  necessary. 

English  catheters  should  be  kept  mounted  on  a  stylet  of  proper 
curve,  and  be  immersed  in  the  antiseptic  solution  (formalin  or  carbolic 
acid)  for  a  half-hour  before  they  are  used;  they  should  then  be  thor- 
oughly cleansed  and  dried.  Freyer  is  quite  content  if  he  can  accustom 
his  patients  to  the  conscientious  use  of  soap  and  hot  water.  The  hands, 
foreskin,  glans  penis,  and  the  urethra  of  the  patient  should  be  suitably 
prepared  for  catheterization,  as  directed  elsewhere. 

When  the  patient  travels,  he  must  be  able  to  carry  his  catheter  with 
him  in  an  aseptic  and  yet  not  too  bulky  a  form.  For  this  purpose 
various  pocket  cases  are  found  in  the  shops,  of  which  the  best  are  made 
of  metal,  so  that  some  formalinized  cotton  can  be  kept  in  them  along 
with  the  catheter,  which  is  coiled  up  so  as  to  occupy  less  space.  An 
ordinary  metallic  soap-box  may  be  used. 

(c)  Lubricant. — For  many  years  olive  or  castor  oil  has  been  employed 
as  a  lubricant  for  catheters.  These  substances  may  be  sterilized  by 
boiling,  but  unfortunately  they  do  not  remain  sterile  very  long;  and  the 
addition  of  strong  antiseptics  is  very  apt  to  roughen  the  surface  of 
webbed  instruments  in  time,  or  else  is  ineffectual  in  sterilizing  the  oil. 
Yet  we  are  quite  satisfied  to  use  carbolized  olive  oil  of  the  strength 
of  one  to  twenty.  Senn  recommended  '*  sterilized  vaseline,  with  the 
addition  of  2^  per  cent,  carbolic  acid  or  i  per  cent,  of  formic  aldehyd. " 
Burckhardt  prefers  a  one  per  cent,  solution  of  salicylic  acid  in  sterilized 
olive  oil;  while,  as  already  mentioned,  Wolff  lubricates  and  at  the  same 
time  sterilizes  his  catheters  in  a  one  per  cent,  sublimated  solution  of 
glycerine  and  water.  An  aqueous  solution  of  boroglycerine  is  another 
useful  lubricant.  The  preparations  on  the  market  consist  of  Iceland 
moss  in  various  combinations  containing  formalin,  carbolic  acid, 
oxycyanid  of  mercury  or  other  antiseptic. 


Passing  the  Catheter 


20  = 


Dr.  E.  Wood  Ruggles  has  offered  the  following  formula  which  is 
essentially  the  same  and  quite  as  good  as  the  best  lubricants  sold  under 
trade  names. 

Dissolve  I  cm.  of  oxycyanid  of  mercury  in  200  cc.  of  hot  sterile 
water;  add  35  cc.  of  glycerine  and  water  enough  to  make  350  cc. 
After  this  mixture  has  cooled  add  10-15  g^i-  of  gum  tragacanth.  After 
standing  for  several  days  the  lubricant  is  ready  for  use. 

When  the  patient  catheterizes  himself,  it  is  far  safer  as  well  as  more 
convenient  for  him  to  be  provided  with  numerous  flasks  or  sterile 
collapsible  paint  tubes  each  containing  ten  cubic  centimetres  of  the 
lubricant,  which  he  then  squeezes  directly  into  the  urethra,  thus  mini- 
mizing the  risk  of  infection. 

(d)  Method  of  Passing  Catheter.— The  choice  of  catheters  should 
always  be  for  the  soft-rubber  first,  then  for  theMercier,  then  the  English, 
and  finally,  in  rare  instances,  the  metallic  instrument.  There  is  prob- 
ably no  department  of  surgery  in  which  practice,  habit,  natural 
aptitude,  a  hght  hand,  good  temper,  and  patience,  are  of  such  paramount 
importance  as  in  catheterization.  It  will  seem  to  the  patient  as  if 
one  surgeon  rushed  at  him  from  the  other  end  of  the  room  with  a  crow- 
bar in  his  hand,  prepared  to  plunge  it  into  the  unfortunate  man's  ure- 
thra, while  another  surgeon  will  gain  entrance  to  the  bladder  before  the 
patient  has  really  become  aware  of  his  maneuvres.  And  it  is  next  to 
impossible  to  incuicate  by  precept  the  many  tricks  which  may  be 
required  to  insinuate  a  rebellious  catheter  into  an  obstructed  urethra; 
only  by  example  and  long-continued  practice  may  the  uninitiated  learn 
these  matters. 

It  is  always  good  to  have  clean  hands,  and  should  be  a  characteristic 
of  the  surgeon;  but  where  a  flexible  catheter  is  to  be  passed  ordinary 
cleanliness  will  not  suffice.  As  it  is  necessary  always  to  hold  such  an 
instrument  close  to  its  point  of  entrance  into  the  urethra,  and  as  there- 
fore it  must  be  fingered  throughout  its  whole  length  during  its  intro- 
duction, the  surgeon's  hands  should  be  sterilized  as  for  a  serious 
operation  before  he  presumes  to  touch  the  sterile  catheter. 

The  glans  penis  and  the  foreskin  of  the  patient  should  be  washed 
with  soap  and  water,  the  fatty  substances  then  removed  with  70 
per  cent,  alcohol,  and  finally  the  glans  should  be  rinsed  with  corrosive 
subhmate  solution  (i  to  1000);  the  anterior  urethra  should  next  be 
flushed  out,  first,  if  possible,  by  directing  the  patient  to  pass  what  urine 
he  is  able  to,  and  then  by  an  injection  of  boric  acid  solution  (2  per 
cent.).     The  catheter  then  being  taken  in  hand,  should  be  thoroughly 


206 


Catheterism 


lubricated  by  being  dipped  in  a  sufficient  quantity  of  the  lubricant, 
which  is  then  allowed  to  run  up  its  whole  length;  or  an  injection  of  the 
lubricating  fluid  may  be  made  directly  into  the  urethra.  The  end  of 
the  catheter  is  then  to  be  carefully  inserted  into  the  meatus .  We  may  say 
here  that  where  there  is  a  prospect  of  oft-repeated  and  long-contined 
use  of  the  catheter,  we  think  it  wisest  to  do  a  meatotomy  at  once,  when 
the  meatus  is  not  amply  large. 

The  Nelaton  catheter  is  so  flexible  that  it  must,  as  already  men- 
tioned, be  held  close  to  the  penis,  and  urged  forward  25  mm.  or  less 


Fig.    64. — Aseptic  Cases  for  Catheters. 
The  U-shaped  tube  has  a  special  flask  for  the  lubricating  fluid. 

at  a  time.  In  fact,  the  urethra  should  seem  rather  to  swallow  the 
catheter  than  that  the  latter  was  being  forced  in.  It  is  well  to  know 
just  how  long  the  catheter  is,  so  that  the  amount  already  introduced 
may  be  readily  gauged  from  the  portion  which  still  remains  within 
the  hands.  If  when  the  tip  of  the  catheter  has  reached  the  prostatic 
urethra  it  will  not  readily  pass  onwards,  the  finger  should  trace  its  course 
through  the  perineum  and  from  within  the  anus,  and  an  attempt  should 
be  made  to  direct  it  on  into  the  bladder.  If  the  catheter  feels  firmly  im- 
bedded, it  should  be  partly  withdrawn,  and  then  again  passed  forward 
with  a  quicker  and  somewhat  rotatory  motion,  as  its  tip  may  have'been 
engaged  in  a  false  passage  or  entangled  in  a  fold  of  mucous  membrane. 
At  the  same  time,  with  the  finger  in  the  rectum  the  catheter's  point 
should  be  kept  against  the  upper  wall  of  the  urethra,  out  of  the  usual 


Passing  the  Catheter  207 

neighborhood  of  false  passages  and  obstructions.  If,  finally,  no 
reasonable  endeavors  will  succeed  in  introducing  the  soft-rubber 
catheter  into  the  bladder,  this  instrument  should  be  withdrawn,  and  a 
Mercier  elbowed  catheter  passed.  The  manner  in  which  this  catheter 
is  to  be  handled  does  not  differ  materially  from  that  just  described;  but 
it  should  be  the  surgeon's  care  that  the  elbowed  beak  follows  the  roof 
of  the  urethra,  as  it  will  thus  be  more  hkely  to  glide  over  the  raised 
internal  orifice  of  this  canal. 

The  Mercier  catheter  also  failing,  the  surgeon  should  next 
attempt  the  Enghsh  catheter,  moulding  it  to  a  proper  curve  before 
introducing  it  into  the  urethra.  If  it  will  not  pass  without  the  stylet, 
it  should  be  withdrawn,  and  then  re-introduced  with  the  stylet  in 
place.  When  the  obstruction  previously  encountered  is  again  met,  if 
slight  persistence  in  pressing  the  handle  well  down  between  the  patient's 
thighs  will  not  cause  the  beak  of  the  catheter  to  surmount  the  ob- 
struction, the  surgeon  may  by  withdrawing  the  stylet  about  twelve 
mm.  raise  the  beak  a  sufficient  distance  to  enable  it  to  ride  over  the 
prominence  of  the  prostate.  It  is  very  rarely  necessary  to  employ 
silver  catheters  in  recent  cases — that  is  to  say,  in  cases  where  the  urethra 
has  not  been  much  tampered  with  by  other  instruments.  Occasionally, 
however,  where  there  has  been  long-standing  inflammation  of  the 
parts  about  the  prostate  and  the  vesical  neck,  the  tissues  are  so  hard 
and  resistant  that  although  no  real  mechanical  obstruction  may  exist 
to  the  passage  of  a  catheter,  yet  the  flexible  and  semiflexible  instruments 
are  not  strong  enough  to  press  apart  the  sclerosed  structures.  In  such 
cases,  the  use  of  a  metallic  catheter  may  be  indispensable;  but  in  em- 
ploying one  it  should  be  constantly  borne  in  mind  that  even  the  very 
minute  amount  of  force  that  is  justifiable  here  will  do  an  incalculable 
amount  of  damage  unless  the  channel  of  the  urethra  is  strictly  adhered 
to.  Hence  the  surgeon  should  make  it  a  golden  rule  to  cling  close 
to  the  roof  of  the  urethra,  and  never  for  an  instant  to  use  any  degree 
of  force,  however  slight,  out  of  the  median  line.  He  will  be  far  more 
apt  to  succeed  in  the  object  he  has  in  view  if  he  keeps  cool  and  avoids 
metal  instruments. 

If  the  first  examination  of  the  patient  has  been  conducted  in  the 
manner  advised  in  Chapter  VII,  much  valuable  information  will  have 
been  acquired  as  to  the  character  of  the  urethra  and  its  obstructions,  so 
that  at  a  later  date  catheters  can  be  passed  with  a  fair  amount  of 
intelligence  and  certainty. 

The  patient  should  use  the  catheter  which  is  most  easily  passed; 


2o8  Catheterism 

but  he  should  never  be  allowed  a  metallic  instrument.  The  soft-rubber 
catheter  is  the  most  harmless,  but  so  great  seems  to  us  the  danger 
of  infection  from  the  necessity  of  handling  it  so  extensively  during  its 
introduction — an  objection  which  applies  also,  though  in  less  degree, 
to  the  Mercier  catheter — that  we  have  a  strong  preference  for  the  English 
catheter  for  the  patient's  use.  These  catheters  are  so  firm  as  to  be 
readily  introduced  by  holding  their  outer  end  only,  as  with  the  metalHc 
catheter,  and  are  at  the  same  time  sufficiently  flexible  to  render  them 
safe  even  in  not  very  skillful  hands.  Under  these  circumstances  they 
should,  of  course,  be  passed  without  the  stylet. 

The  frequency  with  which  a  prostatic  should  be  catheterized  depends 
entirely  upon  the  distress  occasioned  by  the  residual  urine,  provided 
always  that  the  latter  is  not  increasing  in  quantity.  As  a  rule,  however, 
it  will  be  found  that  when  a  patient  has  as  much  as  120  cc.  of  resid- 
ual urine  he  will  be  so  regularly  disturbed  at  m'ght  as  to  require  the 
complete  evacuation  of  his  bladder  by  catheterization  once  in  the 
twenty-four  hours.  The  most  suitable  time  for  this  evacuation  is  just 
before  retiring  for  the  night.  It  is  the  least  inconvenient  time  possible 
for  the  careful  attention  to  personal  and  instrumental  preparation,  and 
is  also  a  time  when  the  emptying  of  the  bladder  will  be  apt  to  give 
the  longest  relief  for  the  ensuing  night. 

Many  a  patient,  nevertheless,  who  has  this  amount  or  even  more 
of  residual  urine  will  not  be  sufficiently  inconvenienced  by  it  to  necessi- 
tate regular  catheterization  at  all.  The  surgeon  should  not,  on  the 
other  hand,  dismiss  such  a  patient  from  his  care,  but  should  attentively 
watch  him,  and  by  passing  a  catheter  every  three  or  four  months  ascer- 
tain whether  the  residual  urine  is  increasing.  It  is  in  just  such  quiescent 
cases  as  these  that  the  residual  urine  accumulates,  increment  by  in- 
crement, until  atony  of  the  bladder  is  well  advanced,  and  overflow  from 
retention  occurs;  or  absolute  retention  with  complete  dependence  on  the 
catheter  makes  the  remaining  days  of  the  patient  one  long  drama  of 
misery. 

If  the  residual  urine,  therefore,  is  found  in  the  course  of  weeks  or 
months  to  be  steadily  increasing  in  quantity,  the  surgeon  should  not 
hesitate,  even  though  no  compelling  symptoms  exist,  to  resort  at  once 
to  habitual  catheterization,  as  the  only  preventive  of  vesical  atony. 

Under  either  of  these  circumstances  then — the  presence  of  symptoms, 
or  the  steady  increase  in  residual  urine  without  symptoms — the  catheter 
should  be  used  once  in  the  twenty-four  hours  for  120  cc.  or  less  of 
residual  urine.     If  180  cc.  are  present,  use  it  twice,  night  and  morning; 


Cystitis  209 

and  add  one  more  catheterization  for  each  additional  60  cc.  of  urine 
up  to  six  times  daily.  When  the  required  number  of  catheterizations 
exceeds  this  limit,  some  other  form  of  treatment  is  urgently  demanded, 
even  though  catheterism  appears  to  maintain  the  patient's  normal 
health. 

3.  Prevention  of  Complications.— The  most  serious  compHcations 
which  it  is  our  duty  to  endeavor  to  prevent  are  cystitis,  retention  of 
urine  in  all  its  varieties,  calculus,  Bright's  disease,  and  uremia. 

Cystitis. — The  causes  of  cystitis  in  cases  of  enlargement  of  the 
prostate  being  almost  exclusively  infection  from  without  through  instru- 
mentation, the  paramount  importance  of  aseptic  habits  in  this  particular 
is  readily  recognized.  All  that  was  said  as  to  the  means  of  sterilizing 
urethral  instruments,  the  manner  of  introducing  them,  and  the  state 
of  the  surgeon's  hands  and  of  the  patient's  urethra,  glans  penis,  and 
foreskin,  should  be  borne  in  mind;  as  far  as  possible  all  instrumentation 
should  be  avoided;  and,  moreover,  the  diet  and  drugs  habitually  advised 
should  be  such  as  to  prevent  vesical  congestion  or  irritability.  The  state 
of  the  urine  should  be  closely  watched,  and  over-acidity  or  alkalinity 
strenuously  combated.  If  strictures  exist,  the  prevention  of  cystitis  is 
even  more  important,  as  the  bladder  will  have  been  in  a  state  of  less 
resistance  for  some  time.  Hence  the  strictures  should  be  systematically 
dilated,  the  benefits  derived  from  this  treatment  when  carefully  con- 
ducted far  outweighing  the  dangers  of  infection.  The  passage  of  large- 
sized  steel  sounds  through  the  prostatic  urethra  also  will  tend  to  prevent 
progressive  obstruction  from  the  diseased  organ,  in  accordance  with  the 
teachings  of  Reginald  Harrison;  and  by  thus  maintaining  an  open 
channel  for  the  urine,  may  postpone  if  not  entirely  prevent  the  develop- 
ment of  cystitis. 

Although  the  prevention  of  cystitis  is  so  important  a  part  of  treat- 
ment, it  is  a  sad  fact  that  the  treatment  of  fully  developed  cystitis 
constitutes  the  greatest  part  of  the  surgeon's  labor  in  these  cases;  and 
this  is  perhaps  so  because  an  uninfiamed  bladder  rarely  gives  rise  to 
feelings  of  discomfort  on  the  patient's  part  or  of  anxiety  on  the  part  of 
his  attendant.  But  some  patients  are  so  subject  to  urinary  fever,  that 
although  they  may  recover  from  an  attack,  yet,  this  complication  being 
ever  present  in  the  minds  of  both  surgeon  and  patient,  extraordinary 
methods  are  necessary  to  avoid  its  recurrence.  In  these  patients  more 
than  any  others  should  instrumentation  be  as  limited  as  possible,  and 
when  necessary  the  most  "pedantic  precautions"  (Senn)  against  infec- 
tion should  be  observed.     Quinine  or  opium,  or  both,  should  be  adminis- 


2IO  Prevention  of  Complications 

tered  some  hours  before  the  catheter  is  used,  and  should  be  repeated 
at  intervals  of  three  or  four  hours  afterwards  until  all  danger  of  chills 
and  other  infective  manifestations  has  passed.  As  it  is  probable  that 
both  urethral  and  urinary  fevers  are  occasionally  due  to  the  septic 
condition  of  the  urine  itself,  and  not  to  any  new  infection  carried  in  by 
the  instrument,  it  is  well  also  to  give  these  patients  a  course  of  urinary 
antiseptics,  such  as  salol,  urotropin,  sodium  benzoate,  etc.  Since, 
moreover,  these  manifestations  of  infection  are  predisposed  to  by  inter- 
stitial nephritis,  every  effort  should  be  made  from  the  beginning  of  treat- 
ment to  get  the  kidneys  into  good  working  order  and  to  keep  them  so. 

Retention  of  Urine. — There  are  several  varieties  of  retention  of  urine, 
which  it  will  be  convenient  to  define  at  the  outset,  that  we  may  know 
the  conditions  indicated  by  each  term:  (i)  Acute  Complete  Retention: 
where  the  patient,  who  was  before  able  to  evacuate  his  urine  wholly  or 
in  part,  becomes  unable  to  do  so — all  the  urine  is  retained,  and  the 
condition  is  acute.  (2)  Chronic  Complete  Retention,  where  the  patient 
depends  absolutely  upon  the  catheter  as  a  means  of  emptying  his 
bladder,  being  unable,  quite  as  much  as  in  the  first  variety  of  retention, 
to  expel  a  single  drop  of  his  own  accord — all  his  urine  is  retained,  but 
the  condition  is  chronic.  (3)  Chronic  Incomplete  Retention  without 
Distention  of  the  Bladder,  where  a  certain  portion  of  urine  is  constantly 
retained,  but  where  the  major  portion  is  evacuated  voluntarily — a 
chronic  condition,  where,  without  the  bladder  being  overfilled,  residual 
urine  exists.  (4)  Chronic  Incomplete  Retention  with  Distention  of  the 
Bladder,  where  so  much  of  the  urine  is  retained  that  the  bladder  has 
reached  the  limit  of  its  capacity,  and  overflow  from  retention  results. 

Guy  on  mentions  still  another  variety  of  retention,  which  he  terms 
acute  incomplete  retention,  and  says  it  is  very  rare.  We  ourselves 
have  not  observed  such  a  condition,  and  as  M.  Guy  on  leaves  its 
symptoms  somewhat  to  the  imagination,  we  are  unable  to  describe  it 
more  fully  than  by  giving  its  title. 

Acute  Retention. — 

1.  Acute  Complete  Retention. 

Chronic  Retention. — 

2.  Chronic  Complete  Retention. 

3.  Chronic    Incomplete    Retention    without    Distention.     (Residual 
Urine.) 

4.  Chronic  Incomplete  Retention  with  Distention.     (Retention  with 
Overflow.) 

The  first  variety  may  attack  either  a  patient  with  no  residual  urine, 


Retention   of  Urine  211 

or  one  in  whom  the  urine  has  been  partly  retained  for  some  time.  In 
either  case  it  is  almost  invariably  due  to  a  sudden  increase  of  congestion 
in  the  prostatic  urethra  and  the  vesical  neck.  Hence  for  its  prevention 
all  those  things  should  be  avoided  which  have  already  been  mentioned 
as  favoring  this  state  of  affairs:  Exposure,  chilling  of  the  skin,  wet 
feet;  retaining  the  urine  an  undue  time;  eating  or  drinking  too  freely; 
lying  too  long  abed. 

The  second  variety,  chronic  complete  retention,  is  almost  invari- 
ably the  result  of  absolute  atony  of  the  bladder.  It  arises  probably 
most  frequently  as  a  consequence  of  the  third  variety,  where  the  residual 
urine  slowly  accumulating  ultimately  entirely  overcomes  the  power  of 
the  bladder  to  contract  and  expel  any  portion  of  its  contents.  In  some 
instances  it  is  due  to  mechanical  obstruction  from  the  growing  prostate, 
which  prevents,  even  if  the  tone  of  the  bladder  is  preserved,  any  urine 
from  being  expelled.  In  exceptional  cases  retention  of  this  kind  succeeds 
immediately  upon  acute  retention,  the  bladder  being  then  so  very  much 
distended  that  it  never  regains  its  contractility.  This  complication 
hence  is  to  be  prevented  by  regularly  evacuating  the  residual  urine  by 
catheterization,  and  at  times  by  moulding  the  prostate  as  it  grows,  so  as 
to  keep  an  open  water-way  from  the  bladder;  also  by  preventing  acute 
retention. 

The  third  variety,  that  where  a  varying  amount  of  residual  urine 
is  present,  is  the  nearly  universal  state  of  prostatics,  and  is  practically 
unpreventable.  In  the  early  stages  of  enlargement,  if  no  residual  urine 
exists,  absence  of  symptoms  is  usual,  and  instrumentation  in  an  attempt 
to  hinder  the  growth  of  the  prostate  by  pressure  will  be  more  likely  to 
cause  cystitis  or  prostatitis  than  to  prevent  the  development  of  a  post- 
prostatic  pouch. 

The  fourth  variety,  retention  with  overflow,  succeeds  upon  the 
third  when  a  very  small  amount  of  contractile  force  is  still  preserved 
in  the  bladder,  and  when  the  urethra  is  not  absolutely  obstructed  by 
the  prostatic  growth.  It  rarely  occurs  where  cystitis  is  present;  and  is 
best  prevented  by  regular  aseptic  catheterization  during  the  earlier 
stages  of  the  disease. 

Atony  of  the  Bladder. — Atony  of  the  bladder,  it  is  thus  seen,  is  an 
even  more  dreaded  accompaniment  of  prostatic  obstruction  then  reten- 
tion of  urine,  of  whatever  variety;  for  where  atony  is  extreme,  it  cannot 
be  remedied  even  by  restoration  of  the  urethra  and  vesical  neck  to  their 
normal  condition.  Even  though  the  whole  obstructing  prostate  be 
removed  successfully,  and  an  easy  entrance  to  the  bladder  be  gained 


212  Prevention  of  Complications 

by  catheters,  yet  the  power  of  contractility  lost  from  prolonged  over- 
distention  will  in  some  few  cases  never  be  regaineb.  Fortunately, 
however,  prognosis  is  no  longer  so  gloomy  as  it  was  only  a  few  years  ago. 
We  have  learned  through  the  brilliant  successes  of  Freyer  and  other 
surgeons  that  in  some  instances  where  for  fifteen  or  twenty  years  the 
patients  had  depended  absolutely  on  the  catheter  for  the  evacuation 
of  every  drop  of  urine — the  complete  removal  of  the  enlarged  prostate 
has  within  a  few  months  or  even  weeks  brought  back  contractility  and 
good  expulsive  power  to  bladders  that  were  thought  before  operation  to 
be  hoplessly  diseased.  And  although,  as  we  say,  we  can  no  longer  regard 
atony  which  is  apparently  complete  as  entirely  irremediable,  we  should 
nevertheless  spare  no  pains  to  prevent  its  development.  To  this  end 
the  bladder  should  never  be  allowed  to  become  distended.  Where  the 
catheter  is  employed  habitually,  great  pains  should  be  taken  to  ensure 
its  entrance  into  the  bladder  with  the  evacuation  of  all  the  residual 
urine,  not  merely  drawing  off  the  small  amount  that  may  exist  in  the 
dilated  prostatic  urethra,  and  leaving  the  true  residual  urine  to  accumu- 
late until  either  complete  chronic  retention  or  retention  with  overflow 
has  developed.  And  where  the  catheter  is  not  habitually  employed, 
nothing  should  prevent  regular  periodical  examinations  to  determine 
the  question  whether  the  residual  urine  is  increasing  or  not. 

Calculus. — The  prevention  of  the  formation  of  calculi  in  the  bladder 
applies  not  alone  to  those  means  usually  employed  in  patients  where  no 
prostatic  enlargement  exists;  for  in  prostatics  we  have  constantly  present 
a  stagnant  pool  of  urine  in  the  bladder,  ready  at  any  moment  of  neglect 
to  crystalhze  around  a  blood  clot  or  a  plug  of  mucus  or  pus.  The 
customary  dietetic  treatment  must  be  employed;  the  urine  should  be 
carefully  watched,  and  maintained  in  a  dilute  and  non-irritating  condi- 
tion; and  the  residual  urine  should  be  systematically  evacuated.  In 
patients  with  a  family  history  of  calculus,  or  with  a  lithemic  tendency, 
the  rule  of  non-interference  with  quiescent  bladders  where  the  amount 
of  residual  urine  is  not  increasing,  must  be  abandoned;  and  on  any 
occurrence  of  bladder  irritability  a  stone  should  be  carefully  searched 
for. 

Hemorrhage  into  the  Bladder. — This  is  a  complication  of  extreme 
gravity.  If  cystitis  does  not  already  exist,  infection  is  practically  sure 
to  arise  as  soon  as  any  amount  of  blood  accumulates  in  the  bladder. 
Hemorrhage  may  occur  spontaneously,  but  is  usually  due  to  rough  or 
careless  instrumentation.  The  site  of  the  bleeding  is  frequently  the 
prostatic  urethra,  whose  upper  wall  may  be  lined  with  distended  vari- 


Renal  Complications  213 

cose  veins;  but  it  most  often  arises  from  a  point  on  the  prostate  which  is 
habitually  abraded  by  the  introduction  of  a  catheter.  Occasionally  it 
follows  upon  the  complete  sudden  evacuation  of  a  distended  bladder 
from  the  relief  of  intravesical  pressure,  being  then  in  the  nature  of  a 
general  ooze  from  the  mucous  membrane.  Calculous  concretions  are 
at  times  the  exciting  cause.  In  any  case,  the  surest  method  of  preven- 
tion is  the  continued  use  of  the  utmost  gentleness  in  all  manipulations. 
There  is  little  doubt  but  that  some  cases  exist  where  even  the  most  skill- 
ful and  gentle  surgeon  cannot  avoid  provoking  bleeding;  but  far  more 
often  it  is  directly  due  to  culpable  negligence  or  ignorance  on  the  part  of 
the  person  who  attempts  catheterization.  The  use  of  flexible  or  semi- 
flexible  instruments  is,  as  often  before  insisted  upon,  infinitely  less 
harmful;  and  with  their  use  hemorrhage  from  traumatism  is  least 
likely  to  occur;  in  rare  cases,  however,  its  recurrence  is  most  readily 
obviated  by  recourse  to  a  metal  catheter  of  large  calibre  and  of  an 
eminently  fit  curve — one  that  has  been  proved  on  previous  occasions 
to  enter  with  facility  the  bladder  of  this  particular  patient.  The  habit 
of  employing  metal  catheters  is,  however,  a  pernicious  one,  and  only  a 
surgeon  with  the  greatest  patience,  the  deftest  and  lightest  hand,  should 
feel  himself  qualified  to  introduce  one  in  cases  such  as  this. 

As  mentioned  above,  hematuria  at  times  supervenes  upon  the 
sudden  complete  withdrawal  of  intravesical  pressure;  so  that  this  is  a 
reason  against  the  indiscriminate  emptying  of  chronically  distended 
bladders,  in  addition  to  the  danger  of  syncope  and  renal  complications. 

Orchitis.— Orchitis  is  a  complication  to  which  some  patients  seem 
peculiarly  liable,  attacks  recurring  again  and  again,  oftentimes  from  no 
apparent  cause.  Usually,  however,  the  affection  may  be  traced  to 
infection  from  instrumentation,  and  is  hence  best  prevented  by  limiting 
instrumentation  as  much  as  may  be,  or  by  avoiding  it  altogether,  should 
this  be  practicable.  Vesical  and  prostatic  congestions  should  also  be 
avoided  by  the  methods  already  indicated  on  previous  pages. 

Renal  Complications  and  Uremia. — Finally,  nephritis,  surgical 
kidneys,  and  uremia  must  be  prevented  if  possible  from  becoming 
complications  of  this  already  sufficiently  troublesome  disease. 

Carefully  selected  food,  plenty  of  fluid,  and  good  bladder  drainage 
are  the  most  important  means  by  which  renal  complications  may  be 
avoided.  Increase  of  renal  pressure  from  damming  up  of  the  urine 
is  one  of  the  most  unfailing  causes  of  renal  insufficiency;  and  is,  of  course; 
best  prevented  by  securing  a  free  outlet  of  urine  from  the  bladder.  For 
this  purpose  catheterization  will   usually  suffice;  but  when  kidney 


214  Treatment  of  Complications 

breakdown  is  threatened  from  backward  pressure  which  cannot  be 
otherwise  satisfactorily  overcome,  we  think  there  can  be  no  doubt  that 
permanent  drainage  of  the  bladder  is  indicated.  If  feasible,  this  should 
be  procured  through  a  permanently  retained  catheter;  but  should  such 
a  course  not  be  possible,  or  should  it  have  failed  to  avert  the  impending 
disaster,  no  hesitancy  should  be  entertained  about  opening  the  bladder 
suprapubically,  and  thus  establishing  an  artificial  urethra  which  will 
at  once  relieve  the  kidneys  of  injurious  pressure.  The  choice  between 
the  two  operations — suprapubic  or  perineal — will  be  considered 
when  discussing  the  treatment  of  complications. 

By  thus  relieving  the  backward  pressure  on  the  kidneys,  and  by 
preventing  the  development  of  cystitis,  the  renal  condition  of  these 
patients  will  be  kept  as  nearly  normal  as  possible;  and  when  this  is 
the  case,  little  fear  need  be  entertained  of  their  being  overwhelmed  by 
uremic  symptoms;  but  it  is  only  by  the  strictest  attention  to  the  state 
of  the  urine  on  the  one  hand,  and  to  that  of  the  circulation  on  the  other, 
that  the  kidneys  can  be  maintained  in  suitable  condition. 

4.  Treatment  of  Complications.  Cystitis. — Cystitis  is  treated  both 
locally  and  constitutionally.  The  local  treatment  may  be  considered 
under  three  headings:  first,  that  by  means  of  drugs  acting  through 
the  kidneys;  second,  by  means  of  irrigations  and  of  injections  into  the 
bladder;  and  third,  by  means  of  drainage  of  the  bladder. 

In  no  cases  of  cystitis  should  the  constitutional  treatment  be 
neglected.  If  the  inflammation  is  acute,  and  extremely  painful,  rest 
in  bed  should  be  enjoined.  The  diet  should  be  liquid  or  at  most  semi- 
solid. Plenty  of  water  should  be  taken.  Hot  sitz-baths  may  prove 
beneficial,  once  or  oftener  in  the  course  of  twenty-four  hours.  The 
bowels  should  be  well  opened  by  mild  cathartics  or  an  enema. 

In  mild  cases  these  means  alone  may  suffice  to  effect  a  cure,  with- 
in one  or  two  days.  Where  the  pain  is  severe  and  incessant,  an  opiate 
may  be  required;  if  morphine  is  contra-indicated  by  the  state  of  the 
kidneys,  or  other  affection,  some  milder  hypnotic  and  analgesic  may 
be  used.  The  bromides  and  chloral  in  combination  often  act  well; 
hyoscine,  chloretone,  sulphonal,  trional,  or  even  paraldehyde,  valerian,  * 
or  asafoetida,  may  act  benefically. 

The  condition  of  the  urine  is  an  all-important  guide  to  further  me- 
dicinal treatment.  Acid  urine,  as  previously  mentioned,  is  best  neu- 
tralized by  reducing  the  amount  of  sugar  ingested,  diluting  the  urine  by 
an  increase  in  the  quantity  of  fluid  taken,  and  by  certain  of  the  alka- 
line waters.     Where  the  urine  is  alkaline  we  may  resort  to  the  usual 


Irrigation  of  the  Bladder  215 

remedies,  such  as  boric  or  benzoic  acid,  sodium  benzoate,  urotropin,  etc. 
As  an  exceptionally  useful  urinary  antiseptic  we  recommend  salol. 

The  aseptic  and  regular  employment  of  the  catheter,  to  remove  any 
residual  urine,  is  frequently  enough  in  itself  to  restore  the  bladder  to 
its  normal  state. 

Combined  with  remedies  such  as  the  above,  where  the  alkalinity  of 
the  urine  is  not  readily  overcome,  or  where  there  is  much  pus  or  blood 
present,  the  bladder  should  be  washed  out.  As  a  rule,  the  best  solution 
is  the  decinormal  solution  of  sodium  chloride,  which  may  readily  be 
improvised  by  adding  a  teaspoonful  of  common  table  salt  to  a  half  a 
litre  of  sterile  water.  The  proper  solution  consists  of  sodium  chloride, 
six  gm.  sodium  bicarbonate,  one  gm.  and  sterile  water,  one  litre.  The 
use  of  drugs  in  the  irrigation  fluid  is  very  rarely  required;  but  boric  acid 
solution  one  half  to  one  gm.  to  each  thirty  cc.  may  at  times  clear  up 
the  urine  sooner  than  the  plain  salt  solution.  Silver  nitrate  should 
never  be  employed  except  in  cases  of  chronic  cystitis;  it  may  be  com- 
menced in  the  strength  of  15  mgr.  to  each  30  cc.  and  if  well  borne,  and 
if  it  appears  that  anything  may  be  gained  by  such  a  course,  the  strength 
may  run  up  to  one  third  to  two  third  gr.  for  each  30  cc.  Great 
care  should  then  be  exercised  that  no  part  of  so  strong  a  solution  comes 
into  contact  with  the  urethra,  which  would  probably  be  much  irritated 
by  it;  but  when  acting  on  the  transitional  epithelium  of  a  bladder 
whose  walls  are  further  protected  by  thick  layers  of  mucus,  and  perhaps 
incrusted  with  salts,  it  does  not  seem  probable  that  any  harm  can  arise. 
Potassium  permanganate,  in  the  strength  of  i  to  4,000  is  at  times  a 
useful  drug. 

The  temperature  of  any  solution  employed  should  be  between  90° 
and  100°  F.;  and  it  should  not  negligently  be  permitted  to  cool  unduly 
during  the  process  of  irrigation.  The  position  of  the  patient  should 
usually  be  supine;  but  where  the  post-prostatic  pouch  is  large  and  diffi- 
cult to  drain,  the  pelvis  may  advantageously  be  raised  six  or  eight  inches. 

The  manner  in  which  the  bladder  irrigations  are  given  is  important. 
It  is  very  much  better  and  more  comfortable  to  the  patient  for  them  to 
be  given  through  a  soft-rubber  or  even  a  Mercier  or  English  catheter; 
but  where  these  cannot  be  introduced  into  the  bladder,  a  metal  catheter 
may  readily  be  utilized  by  attaching  a  rubber  tube  to  its  outer  extrem- 
ity. Two  methods  of  injection  are  used:  the  first  by  means  of  a 
syringe,  holding  at  most  30  cc,  whose  tip  is  carefully  placed  in  the 
outer  end  of  the  catheter,  which  should  be  funnel-shaped  for  its  recep- 
tion; the  other  method  consists  in  attaching  by  means  of  glass  and 


2i6  Treatment  of  Complications 

rubber  tubing,  a  small  funnel,  holding  about  30  cc.  of  water,  into 
which  the  solution  is  poured,  and  from  which  it  is  allowed  to  run  into  the 
bladder  by  the  force  of  gravity.  Where  a  syringe  is  used  for  the 
injection  no  force  whatever  should  be  used  in  pushing  the  piston  home ; 
indeed,  it  will  usually  be  found  that  when  the  syringe  is  held  ver- 
tically the  piston  sinks  upon  the  contained  fluid  by  its  own  weight. 
When  the  tubing  and  funnel  apparatus  is  employed  (and  it  is  the  more 
convenient  when  available),  the  funnel  should  never  be  raised  to  a 
height  of  more  than  two  feet  above  the  patient's  bladder;  usually  the 
fluid  will  run  easily  at  a  height  of  a  few  inches.  Whichever  apparatus 
is  used,  not  more  than  120  cc.  at  the  outside  should  be  thrown  into 
the  bladder  at  any  one  time;  when  this  quantity,  or' less  if  pain  be 
caused,  has  been  injected,  it  should  be  allowed  to  remain  for  ten  or 
fifteen  seconds,  and  then  let  out;  nor  should  the  abdomen  of  the  patient 
be  kneaded  too  vigorously  in  an  effort  to  hurry  the  process.  It  is  a 
form  of  treatment  that  requires  patience  and  time,  and  nothing  is  to  be 
gained  by  haste.  The  bladder  should  not  be  refilled  more  than  four  or 
five  times  at  the  same  sitting,  and  the  operation  should  not  be  repeated, 
except  in  offensive  cases,  oftener  than  once  in  twenty-four  hours. 

Contrary  to  the  general  rule  above  stated:  to  the  effect.that  not  more 
than  120  cc.  of  fluid  should  be  injected  into  the  bladder  at  once, — 
which  rule,  however,  we  invariably  adopt  at  the  first  irrigation, — we 
believe  that  much  good  may  accrue  from  the  passive  but  very  gradual 
distention  of  chronically  inflamed  and  contracted  bladders.  Thus  we 
have  seen  patients  who  at  the  first  sitting  could  not  bear  to  have  more 
than  30  cc.  thrown  into  their  bladder  at  one  time,  in  the  course  of 
a  few  weeks,  regain  lost  bladder  capacity  so  that  instead  of  30  cc, 
three  or  four  finally  six  or  eight  times  the  amount  could  readily 
be  retained;  the  patient  meanwhile  experiencing  a  corresponding  de- 
crease in  the  frequency  of  urination.  But  the  most  gradual  distention 
in  the  world  should  be  practised :  we  are  quite  satisfied  if  we  can  estab- 
lish a  tolerance  for  a  few  cc.  additional  at  each  sitting. 

In  the  practice  of  irrigating  the  bladder  the  attendant,  and  the 
patient  as  well,  will  often  lose  heart  from  the  apparent  slowness  of 
progress  in  the  relief  of  the  cystitis;  and  many  a  time  the  surgeon  will 
feel  tempted  to  throw  a  large  quantity  of  fluid  into  the  bladder  rapidly 
and  with  considerable  force,  in  the  effort  to  clear  its  cavity  of  accumulat- 
ing mucus  and  blood  clots  by  a  process  analogous  to  hydraulic  mining; 
but  let  him  beware  that  he  does  not  adopt  such  a  practice  I  The  sudden 
changes  in  form  to  which  such  methods  would  subject  the  bladder  would 


Irrigation  of  the  Bladder  217 

bdt  augment  the  inflammation,  and  might  possibly  cause  the  rupture 
of  some  of  the  vessels  in  its  walls,  burst  some  thin-walled  sacculi,  or 
carry  infection  into  the  ureters  and  on  the  way  to  the  kidneys.  The 
bladder  itself  might  even  be  ruptured.  It  should  be  remembered  that 
there  is  no  expectation  of  mechanically  ridding  the  bladder  of  the 
products  of  inflammation  and  hemorrhages;  we  are  not  even  operating 
by  a  variety  of  Htholapaxy;  and  however  pleased  we  may  be  when  a 
quantity  of  debris  is  spontaneously  evacuated  through  the  catheter,  we 
must  not  forget,  that  our  object  is  rather  to  prevent  the  persistence 
or  extension  of  the  inflammation  than  to  remove  its  products — we 
hope  that  these  may  dissolve  and  be  passed  by  the  urethra  in  the  natural 
course  of  events. 

But  in  some  cases  these  means  do  not  suffice  to  arrest  the  cystitis; 
the  introduction  of  a  catheter  is  painful,  difficult,  or  even  impossible ; 
the  bladder  irrigations  give  no  relief;  renal  and  uremic  comphcations 
impend,  and  urinary  fever  has  already  set  in.  Under  these  circum- 
stances no  further  delay  should  be  tolerated,  but  as  soon  as  it  is  evident 
that  ground  is  being  lost  the  bladder  should  be  drained. 

Of  course,  the  simplest  way  by  which  this  may  be  accomplished  is 
by  permanently  retaining  a  catheter,  so  that  its  eye  projects  just  within 
the  vesical  cavity,  and  the  urine  is  collected  and  discharged  drop  by 
drop,  just  as  it  is  received  from  the  ureters.  It  is  important  to  have  the 
catheter  neither  too  far  in,  nor  yet  too  far  out  of  the  bladder:  in  the 
former  case  its  tip  will  cause  great  irritation  of  the  vesical  trigone,  while 
in  the  latter  the  drainage  will  be  very  imperfect.  To  ensure  its  being 
in  the  correct  situation,  the  catheter  should  first  be  fully  introduced  into 
the  bladder  until  the  urine  flows  in  a  steady  stream;  then  it  is  to  be 
slowly  withdrawn  until  the  urine  stops  running  entirely,  which  it  does 
when  the  eye  enters  the  urethra;  and  then,  finally,  the  catheter  is  to 
be  pushed  back  again  about  ten  to  twelve  mm.  until  the  urine  escapes 
through  it  by  drops. 

But  it  is  an  exceedingly  difficult  matter  to  keep  a  catheter  perma- 
nently in  the  correct  place.  Many  forms  of  self-retaining  catheters 
have  been  invented,  but  in  our  opinion  there  is  not  one  of  them  which  is 
practically  useful.  The  Nelaton  catheter  should,  if  possible,  be  that 
selected  for  the  purpose,  as  being  perfectly  flexible  it  is  less  apt  to  cause 
irritation.  Some  degree  of  urethritis  is  nearly  unavoidable,  but  with 
in  flexible  instruments  not  only  is  urethritis  more  likely  but  every  change 
inposition  of  the  patient  is  Hable  to  wound  the  prostate,  or  the  bladder; 
besides  which  it  is  very  difficult  to  secure  such  a  catheter  in  place. 


2l8 


Treatment  of  Complications 


For  rubber  catheters  the  appliance  shown  in  Figs.  65  and  66  may  be  used, 
when  it  is  at  hand.  This  consists  of  a  caoutchouc  bridle  attached  at  one 
end  to  the  catheter  at  its  point  of  entrance  into  the  urethra,  and  fastening 
at  the  other  around  the  body  of  the  patient's  penis.  Where  this  is  not 
available  the  catheter  should  be  transfixed  with  a  double  ligature, 
through  the  loops  of  which,  tied  fairly  close  to  the  catheter  on  each 
side,  strips  of  adhesive  plaster  are  to  be  adjusted  and  fastened  in  a  spiral 


Fig.  65. — Catheter  Retainer.     (Caples)  Surgery,  Gynecology  and  Obstetrics, 

and  interlacing  manner  around  the  body  of  the  penis.  If  a  hgature 
cannot  be  procured  in  an  emergency,  the  catheter  may  be  transfixed 
with  a  safety-pin,  and  the  adhesive  plaster  tied  to  that.     Care  should  be 


Fig.  66. — Catheter  Retainer.     (Caples)  Surgery,  Gynecology  and  Obstetrics. 


taken  that  the  attachment  of  the  plaster  to  the  catheter,  in  any  case, 
is  close  to  its  point  of  entrance  into  the  urethra,  thus  preventing  the 
catheter  from  slipping  too  far  in,  as  well  as  keeping  it  from  falling  out. 
Watson  has  suggested  an  ingenious  method  by  which  a  piece  of  rubber 


Cystostomy  219 

drainage  tube,  ten  to  twelve  cm.  and  of  slightly  less  calibre  than  the 
catheter'employed  (so  as  to  grip  it  firmly),  is  passed  over  this  latter, 
thedrainage  tube  being  split  longitudinally  into  two  halves  up  to  with- 
in twenty-five  mm.  of  its  outer  extremity,  and  these  lateral  halves  then 
being  attached  to  the  penis  by  adhesive  plaster  in  the  usual  manner. 
Mercier  and  English  catheters  may  be  fastened  in  by  means  of  a  ligature 
or  safety-pin  as  already  described;  while  a  metal  instrument  is  best 
secured  by  passing  the  middle  tails  of  a  double  T-bandage  through  the 
rings  on  each  side  of  its  shaft. 

The  period  during  which  the  same  catheter  can  be  safely  retained 
without  changing  varies  much  in  different  cases,  and  depends  largely  on 
the  state  of  the  urine;  in  some  patients  the  catheter  will  within  forty- 
eight  hours  become  so  incrusted  with  salts  as  to  make  its  removal 
difficult.  It  appears  that  instruments  made  of  webbing  are  more  liable 
to  the  deposit  of  salts  than  the  soft-rubber  catheter,  and  this  constitutes 
another  objection  to  their  use  for  such  purposes.  Even  when  no  such 
trouble  arises,  the  irritation  to  the  urethra  or  bladder,  or  the  pain 
experienced  by  the  patient  may  render  the  removal  of  the  catheter 
imperative  within  a  comparatively  short  time.  As  a  rule,  one  should 
not  be  left  longer  in  place  without  changing  than  a  week  or  ten  days, 
unless  surety  exists  that  no  crusts  are  forming.  This  question  is  best 
determined  by  previous  experience  with  the  same  patient,  although  the 
condition  of  the  urine  may  serve  as  a  fairly  reliable  guide. 

When  changed  at  suitable  intervals  permanent  drainage  by  a 
catheter  may  be  continued  almost  indefinitely.  Thus  Bazy  kept  a 
Nelaton  catheter  in,  the  bladder  for  eighteen  months,  the  patient  not 
being  confined  to  bed. 

In  some  patients  a  catheter  will  not  stay  in  place;  it  seems  to  work 
its  way  out  either  spontaneously,  or  slips  from  the  urethra  every  time 
the  patient  changes  his  position  in  bed;  while  in  others  a  catheter  will 
stay  securely  in  the  bladder  even  when  the  patients  are  up  and  about, 
and  leading  a  fairly  active  life. 

When  from  any  cause  the  catheter  cannot  be  retained  in  the  urethra 
and  drainage  of  the  bladder  still  continues  to  be  indicated,  cystostomy 
must  be  done.  In  a  certain  proportion  of  cases  immediate  incisional 
drainage  of  the  bladder  is  indicated,  not  however  to  reheve  cystitis 
alone,  but  to  insure  against  continued  back-pressure  on  the  kidneys. 
Cystostomy  has  indeed  become,  in  recent  years,  a  preliminary  step  in 
the  operation  of  suprapubic  prostatectomy,  but  we  still  cling  to  the  beUef 
that  the  two-stage  operation  is  indicated  in  only  a  certain  proportion  of 


2  20  Treatment  of  Complications 

cases  and  that  the  proper  use  of  the  in-dwelling  catheter  will  reduce 
the  proportion  of  such  cases  considerably.  The  two-stage  operation 
is  really  a  development  of  the  idea  which  was  first  expressed  by 
Reginald  Harrison  of  treating  suppurative  nephritis  by  means  of 
perineal  cystostomy.  Cabot,  of  Boston,  later  proposed  the  treatment 
of  patients  with  surgical  kidneys  by  means  of  drainage  of  the  bladder. 
Encouraging  results  were  obtained  by  this  method,  and  it  soon  became 
evident  not  only  that  obstructive  lesions  of  the  lower  urinary  tract 
caused  grave  disturbances  in  kidney  function,  but  also  that  the  relief  of 
back-pressure  by  treatment  preliminary  to  the  removal  of  the  obstructive 
factor  permitted  the  restoration  of  kidney  function  to  a  degree  that  made 
the  subsequent  prostatectomy  a  much  safer  procedure.  In  certain 
cases  the  necessity  for  long-continued  preliminary  treatment,  first 
perhaps  by  intermittent  catheterization,  later  by  in-dwelling  catheter 
or  by  suprapubic  cystostomy,  is  evident,  but  in  a  not  inconsiderable 
number  of  patients  whose  disease  is  in  the  early  stage,  where  the 
obstructive  factor  is  not  pronounced,  and  has  given  rise  to  little  or 
no  deleterious  alteration  in  bladder  or  kidney  function,  we  cannot  see 
the  rationale  of  subjecting  the  individual  to  a  long  series  of  treatments 
designed  for  the  relief  of  something  he  does  not  suffer  from.  The  two- 
stage  operation  should,  in  our  judgment,  be  used  only  in  selected  cases. 

Cystostomy  is  a  very  much  safer  procedure  than  tapping  the  bladder 
and  allowing  the  cannula  to  remain  in  plcae;  and  besides  being  safer, 
affords  the  surgeon  the  additional  advantage  of  digital  or  even  visual 
examination  of  the  interior  of  the  bladder  and  the  prostate,  as  well  as 
enabling  him  to  proceed  to  the  formation  of  an  artificial  urethra,  should 
such  an  operation  be  indicated  at  that  time.  As*a  rule,  suprapubic 
drainage  is  to  be  preferred;  but  in  certain  cases  the  perineal  route  is 
the  better. 

Perineal  drainage,  so  commonly  employed  in  the  early  days  of  pros- 
tatic surgery,  is  now  reserved  for  those  fortunately  rare  cases  of  inter- 
stitial cystitis  with  great  thickening  of  the  bladder  walls,  and  marked  by 
diminished  bladder  capacity. 

These  cases  are  extremely  difl&cult  ones  to  treat  and  the  results 
obtained  are,  to  say  the  least,  not  brilliant.  The  suprapubic  operation 
either  for  simple  drainage  or  with  the  purpose  in  view,  of  some  operative 
procedure  on  the  vesical  neck,  is  unsatisfactory  on  account  of  the  great 
thickness  of  the  bladder  walls  and  the  diminished  bladder  capacity. 

Many  forms  of  operative  treatment  have  been  suggested  for  this 
class  of  cases  and,  doubtless  in  certain  instances,   the  Young  punch 


Acute  Urinary  Retention  221 

or  Chetwood's  galvano-cautery  may  be  used  with  gratifying  results. 
Our  preference,  however,  is  for  perineal  drainage  with  or  without 
prostatectomy,  as  circumstances  indicate. 

In  many  of  these  cases  the  rigidity  of  the  vesical  neck  is  secondary 
to  the  chronic  cystitis.  The  prostate  is  usually  the  seat  of  a  chronic 
interstitial,  inflammatory  process,  and  is  oftentimes  small  in  size  and 
very  indurated;  it  may  or  may  not  be  a  contributing  factor  to  the 
obstructive  lesion  at  the  vesical  neck. 

Operation  should  not  be  attempted  in  these  cases  until  every  effort 
has  been  made  to  bring  some  measure  of  relief  by  urethral  dilatta'on, 
lavage  of  the  bladder,  etc.;  but  having  failed  in  these  attempts  it 
behooves  the  surgeon  to  try  some  form  of  operative  treatment. 

It  is  our  practise  in  operating  upon  these  individuals  to  open  the 
perineum,  and  if  conditions  warrant  it,  to  remove  the  prostate  gland; 
otherwise,  the  vesical  neck  is  merely  dilated  and  a  drainage  tube  of 
large  calibre  is  inserted. 

This  procedure  insures  temporary  relief,  the  duration  of  which  is 
almost  in  direct  ratio  with  the  length  of  time  that  the  drainage  is  con- 
tinued, and  the  care  with  which  the  post-operative  treatment  is  carried 
out. 

Perineal  drainage  as  a  preliminary  step  to  the  operation  of  prostatec- 
tomy is  no  longer  employed;  in  the  presence  of  violent  intractable 
cystitis,  with  the  exception  just  noted,  the  two-stage  operation  of  supra- 
pubic prostatectomy  is  indicated. 

Retention  of  Urine. — (a)  Acute  Complete  Retention  oj  Urine. — 
This  variety  of  urinary  retention  in  prostatics  is  quite  as  serious  an 
affection  as  strangulated  hernia,  and  requires  quite  as  prompt  and 
efficacious  treatment.  The  bladder  may  be  very  greatly  distended 
by  a  small  quantity  of  urine  since  it  may  have  been  chronically  con- 
tracted and  inflamed  for  a  long  time.  The  pain  is  indescribably 
terrible,  and  instantly  grows  worse;  not  only  is  rupture  threatened  every 
moment,  but  the  damming  up  of  the  urine  into  the  ureters  and  kidneys 
renders  urinary  fever  and  uremia  likely ;  and  even  if  rupture  of  the 
bladder  does  not  occur,  peritonitis  by  contiguity  may  soon  develop. 
Since,  moreover,  the  most  usual  cause  of  this  form  of  retention  is  a 
mechanical  obstruction  caused  by  congestion  of  the  prostatic  urethra  or 
the  vesical  neck,  which  congestion  grows  worse  every  moment  the  reten- 
tion is  not  relieved,  it  is  evident  how  idle  it  is  to  resort  to  those  remedies, 
such  as  opium  and  the  hot  bath,  which  are  so  successful  at  times  in  the 
treatment  of  acute  urinary  retention  due  to  spasmodic  or  even  to  organic 


222  Treatment  of  Complications 

stricture.  In  patients  of  the  latter  class  the  retention  is  rarely  absolute 
- — usually  a  few  drops  trickle  through  the  strictures  now  and  again;  and 
the  bladder,  moreover,  is  apt  to  be  in  a  less  unhealthy  state  than 
where  prostatic  disease  has  existed  for  a  long  time. 

Hence  the  only  rational  treatment  for  this  serious  complication  is 
immediate  relief  by  the  catheter.  It  is  very  rarely  indeed  that  a  cathe- 
ter cannot  be  introduced,  provided  no  false  passages  have  been  made  in 
careless  and  forcible  attempts  to  gain  entrance  to  the  bladder  before 
the  case  is  seen.  The  patient  himself,  in  his  agony  of  pain  and  impera- 
tive desire  for  relief,  may  have  produced  false  passages  which  even  the 
most  skillful  catheterization  will  be  unable  to  elude;  or  another  practi- 
tioner with  greater  zeal  than  dexterity  may  likewise  have  rendered  the 
urethra  impassable.  But  in  virgin  urethras,  which  have  not  before 
had  a  catheter  passed,  and  where  no  strictures  are  present,  a  Uttle 
persistence,  and  a  good  deal  of  patience  and  gentleness,  will  almost 
invariably  accomplish  the  desired  result. 

The  soft-rubber  catheter  is  to  be  tried  first;  this  failing,  the  Mercier 
should  be  introduced,  and  its  elbowed  beak  made  to  follow  closely 
the  roof  of  the  urethra;  should  this  also  be  met  by  an  insuperable 
obstruction,  the  EngHsh  webbed  catheter,  moulded  to  a  proper  prostatic 
curve,  may  be  tried,  first  alone,  and  then  with  its  stylet.  If  passed 
with  the  stylet  in  its  interior,  the  beak  of  the  English  catheter  may 
usually  be  lifted  over  the  raised  vesical  orifice  of  the  urethra  by  partially 
withdrawing  the  stylet,  as  already  described.  When  efforts  thus  con- 
scientiously made  also  fail,  metaUic  instruments  may  be  tried;  but  we 
believe  that  a  skillful  surgeon  will  rarely  succeed  with  these  where  he 
has  failed  with  the  Enghsh  catheter  mounted  on  the  stylet.  A  hasty 
and  impatient  surgeon  will  no  doubt  often  succeed  in  introducing  by 
force,  perhaps  by  tunnelling  the  prostate,  a  metallic  instrument  into 
the  bladder,  where  a  little  more  dexterity  and  less  force  would  have 
brought  the  same  result  to  pass  by  means  of  a  semiflexible  instrument 
and  without  injury  to  the  bladder,  prostate,  or  urethra. 

Where  strictures  render  the  urethra  difficult  to  catheterize,  the 
usual  manipulations  employed  in  such  cases  should  be  employed. 
These  it  is  not  necessary  to  describe  in  the  present  work.  It  seems 
scarcely  requisite  to  add  that  wherever  in  genito-urinary  surgery  a 
catheter  has  been  introduced  only  with  the  greatest  difficulty,  it  should 
be  allowed  to  remain  permanently  in  the  bladder  until  all  acute  symp- 
toms have  subsided. 

If,  finally,  no  judicious  efforts  succeed  in  gaining  entrance  to  the 


Chronic  Urinary  Retention  223 

bladder  through  the  urethra,  the  bladder  must  be  tapped.  The  time 
during  which  urethral  instrumentation  should  be  persisted  in  will,  of 
course,  vary  somewhat  with  different  cases;  but,  as  a  rule,  we  do  not  think 
such  attempts  should  be  prolonged  more  than  a  half  hour  or  forty-five 
minutes.  Even  this  length  of  time  will  be  injudicious  where  the 
retention  has  lasted  for  more  than  a  few  hours  at  most. 

While  we  recommend  tapping  of  the  bladder  as  the  next  step,  we 
recognize  that  it  must  be  only  a  temporary  expedient;  since  it  is  very 
exceptional  for  the  power  of  voluntary  micturition  through  a  urethra 
so  much  wounded  and  inflamed  as  these  usually  are,  to  return  within 
any  reasonable  time;  indeed,  as  already  pointed  out,  where  this  acute 
retention  is  allowed  to  exist  for  any  length  of  time,  it  is  not  impossible, 
indeed  scarcely  unusual,  for  chronic  complete  retention  to  follow 
from  atony  of  the  bladder;  so  that  where  a  competent  surgeon  is  in 
attendance,  and  the  surroundings  make  it  suitable,  it  is  best  to  do  a 
suprapubic  cystostomy  at  once;  or  if  the  bladder  is  very  small  and  the 
abdominal  walls  thick,  perineal  drainage  may  be  established,  as  indicated 
in  the  last  section. 

But  where  no  facilities  for  such  operations  exist,  the  bladder  may  be 
safely  punctured  suprapubically,  and  immediate  danger  averted,  and 
the  patient's  pain  temporarily  relieved.  This  procedure  may  be 
repeated  a  number  of  times  without  evil  consequences,  but,  as  long  ago 
pointed  out  by  Dittel,  such  treatment  is  really  only  a  pastime  for  the 
surgeon,  and  is  one  which  should  be  tolerated  only  until  proper  arrange- 
ments for  cystostomy  can  be  made.  When  the  resort  to  cystostomy 
must  be  delayed,  it  may  appear  better  to  retain  the  cannula  in  the  punc- 
ture than  to  reintroduce  it  every  few  hours. 

In  cases  of  acute  retention  it  is  absolutely  unjustifiable  to 
extend  the  palliative  operation  of  cystostomy  to  the  radical  removal 
of  the  prostate. 

{b)  Chronic  Complete  Retention  of  Urine.— li  atony  of  the  bladder 
exists  in  cases  of  this  variety,  as  can  readily  be  determined  by  the  degree 
of  force  with  which  the  urine  is  expelled  through  a  catheter,  it  will  be 
proper  to  make  use  of  drainage  of  the  bladder  by  a  permanent  catheter, 
in  the  hope  that  the  chronic  retention  may  be  due  to  the  atony  alone, 
and  not  to  mechanical  obstruction  by  the  enlarged  prostate.  By 
this  method  the  bladder  walls  may  in  the  course  of  a  few  weeks  recover 
their  contractility,  as  evidenced  by  increasing  force  in  any  stream 
(whether  of  urine  or  irrigation  fluid)  expelled  through  the  catheter.  If 
the   atony   is   thus   relieved,   it  still  remains  to  determine  whether 


2  24  Treatment  of  Complications 

the  mechanical  prostatic  obstruction  is  too  great  to  be  overcome  by 
the  restored  bladder  contractility.  This  question  is  readily  answered 
in  the  affirmative  if,  on  discontinuing  the  permanent  drainage,  the 
retention  persists.  In  some  exceptional  cases  it  will  have  been  found 
at  the  very  outset  that  no  atony  of  the  bladder  existed.  Under  either 
of  these  circumstances,  then, — whether  vesical  atony  never  existed, 
or  whether  it  be  easily  recovered  from  after  relief  of  intravesical  pressure 
by  permanent  drainage, — it  is  evident  that  the  retention  is  due  to 
mechanical  prostatic  obstruction.  Hence  the  indication  is  to  remove 
this  by  radical  operation. 

If  atony  did  exist,  and  was  not  relieved  after  permanent  drainage, 
we  are  confronted  with  another  problem:  Will  removal  of  the  pros- 
tate be  any  more  apt  to  relieve  the  vesical  atony  than  was  the 
drainage  of  the  bladder  through  the  catheter?  We  think  this  question 
may  fairly  be  answered  in  the  affirmative;  although  we  would  hesitate 
to  recommend  radical  treatment  to  a  feeble  patient  whose  catheter 
life  was  satisfactory  to  him.  For  there  would  still  remain  the  risk  that 
the  radical  operation  would  leave  him  no  less  dependent  on  the  catheter 
than  he  previously  was;  but  if  his  catheterism  is  painful,  difficult, 
or  unduly  frequent,  and  the  patient  himself  is  not  too  old  and 
feeble  for  any  operation,  we  would  be  inclined  to  advise  him  to  take 
the  risk. 

(c)  Chronic  Incomplete  Retention  oj  Urine  without  Distenlion  oj  the 
Bladder. — Much  of  what  has  been  said  in  the  early  part  of  this  chapter 
under  the  general  heading  of  catheterism,  applies  to  this  complication. 
It  is  a  nearly  invariable  accompaniment  of  every  case  of  enlargement 
of  the  prostate. 

(d)  Chronic  Incomplete  Retention  of  Urine  with  Distention  of  the 
Bladder. — For  these  patients  the  indications  are  first  to  restore  the  full 
measure  of  vesical  contractility,  and  then  to  remove,  if  necessary,  the 
obstructing  prostate. 

The  proper  treatment  to  be  advised  for  prostatics  with  overflow 
from  retention,  is  to  remove  only  a  few — 120  to  180 — cc.  of  urine 
at  a  time,  repeating  this  procedure  every  four  or  five  hours  as 
may  be  required,  and  thus  gradually  to  empty  the  distended  blad- 
der in  the  course  of  two  or  three  days.  Or,  if  desired,  more 
urine  may  be  withdrawn,  and  partially  replaced  with  saline  or  boric 
acid  solution. 

The  above  plan  of  treatment  presupposes  that  the  urethra  is  freely 
open  to  catheterization.     But  this  may  not  be  the  case,  the  urethra 


Calculus  225 

being  obstructed  by  strictures  or  false  passages.  If  a  catheter  can  be 
introduced,  but  only  with  difficulty,  the  surgeon  may  try  to  clamp  it, 
and  leave  it  in  situ,  allowing  a  few  cc.  to  run  off  by  removing  the 
clamp  every  couple  of  hours.  But  if  no  catheter  of  any  kind  can  be 
introduced,  a  filiform  bougie  should  be  tried,  as  in  the  case  of  stricture 
unaccompanied  by  prostatic  enlargement;  when  success  attends  these 
efforts,  the  filiform  should  be  left  in  place,  as  the  urine  will  satisfactorily 
and  not  too  rapidly  drain  off  along  its  track.  If  no  kind  of  instrument 
can  be  introduced,  we  believe  the  proper  course  for  the  surgeon  to  pursue 
is  to  perform  suprapubic  cystostomy,  evacuate  the  urine,  staunch  bleeding 
from  the  mucous  membrane  of  the  bladder  by  the  hot  douche;  and  take 
the  usual  constitutional  precautions  against  the  development  of  surgical 
kidney  and  uremia. 

Aspiration  or  tapping  of  the  bladder  may  be  thought  by  some  a 
preferable  course,  only  a  few  cc.  being  removed  each  time,  and  the 
operation  being  repeated  innumerable  times;  but  such  a  plan  of  treat- 
ment admits  of  no  hope  to  the  patient  save  the  classical  "meditation 
upon  death;"  for  it  is  the  most  improbable  thing  in  the  world  that  the 
urethra  will  again  become  open  to  instrumentation  before  the  "medita- 
tion" of  the  patient  has  passed  into  the  reality.  Suprapubic  cystot- 
omy under  local  anesthesia  is  the  method  of  choice  in  the  treatment  of 
these  cases,  not  only  because  it  is  the  safest  and  best  method  of  relieving 
the  acute  retention  when  catheterization  is  impossible,  but  also  because 
it  offers  the  best  means  of  decompressing  the  kidneys. 

Cystostomy  under  these  circumstances  constitutes  the  first  stage 
of  the  two  stage  prostatectomy.  In  rare  instances,  however,  the  condi- 
tion of  the  patient  following  the  operation  will  not  improve  sufficiently 
to  justify  removal  of  the  prostate;  he  can  then  be  provided  with  a 
cannula  to  be  worn  permanently  in  the  fistula. 

Calculus. — The  most  generally  accepted  plan  of  treatment  for 
calculus  complicating  enlargement  of  the  prostate  is  suprapubic  litho- 
tomy. In  suitable  cases  the  prostate  may  be  removed  at  the  same  time, 
but  it  is  generally  advisable  to  drain  the  bladder  for  a  time  before 
attempting  prostatectomy.  The  latter  operation  should  not  be  under- 
taken until  the  kidney  and  other  vital  functions  have  been  restored 
to  as  near  the  normal  as  possible.  Preliminary  drainage  of  the  bladder 
not  only  aids  in  such  restoration  of  function,  but  serves  also  to  relieve 
the  cystitis  which  usually  accompanies  stone,  and  thus  minimizes  the 
dangers  of  sepsis  and  hemorrhage  after  prostatectomy. 

It  is  sometimes  stated  that  patients  with  enlarged  prostates  com- 

15 


226  Treatment  of  Complications 

plicated  by  stone  bear  operation  better  than  those  in  which  stone  is 
not  a  complicating  factor;  this  view  is  erroneous  in  our  experience  and 
we  can  find  no  statistical  confirmation  of  it. 

Not  a  few  successes  have  been  reported  from  operation  by  lithola- 
paxy  but  the  operation  is  not  to  be  employed  in  patients  with  marked 
intravesical  projection  of  the  prostate. 

We  have  long  since  abandoned  the  operation  of  litholapaxy  yet 
this  procedure  with  or  without  a  Young  punch  operation  may  possibly 
have  a  place  in  the  treatment  of  small  stones  complicating  median  bar 
formation  or  sclerosis  of  the  vesical  neck. 

An  alternative  method  of  treatment  in  cases  of  this  kind  is  that  of 
median  perineal  lithotomy  followed  by  galvano-cauterization  of  the 
vesical  neck.     (Chetwood.) 

Orchitis  is  to  be  treated  as  when  arising  from  other  causes.  Instru- 
mentation should  also  be  discontinued. 

Hemorrhage  into  the  bladder  is  best  treated  by  hot  irrigations, 
and  permanent  drainage,  which  may  be  instituted  by  means  of  a 
suprapubic  wound  if  necessary. 

Renal  Complications  and  Uremia. — For  these  complications  the 
treatment  in  patients  with  enlargement  of  the  prostate  does  not  differ 
materially  from  that  habitually  employed  in  other  cases.  Good  bladder 
drainage  is  imperative.  The  permanently  retained  catheter,  or  supra- 
public  or  perineal  drainage,  may  be  employed,  according  to  the  principles 
already  laid  down.  If  polyuria  is  a  distressing  feature  it  may  be 
partially  relieved  by  reducing  the  amount  of  fluid  ingested,  and  by 
promoting  perspiration.  Care  should  be  exercised  that  atony  of  the 
bladder  from  overdistention  does  not  arise. 

In  the  later  stages  of  renal  affections,  when  the  urine  becomes 
scanty  or  suppressed,  the  usual  increase  in  ingested  fluid  should  be 
prescribed;  and  great  advantage  may  be  derived  from  the  use  of  saline 
solution  by  the  bowel.  A  half  litre  is  readily  absorbed  from  the  colon  in 
the  course  of  an  hour  or  so;  the  temperature  should  be  over  ioo°  F. 
In  sudden  emergencies  intravenous  infusion  of  the  decinormal  salt 
solution  may  be  employed,  it  being  rarely  advisable  to  give  more  than 
one  or  two  litres  at  once  by  this  method.  This  fluid  is  probably  absorbed 
nearly  as  rapidly  from  the  bowel  as  when  given  intravenously,  and 
certainly  more  rapidly  than  when  administered  by  hypodermocylsis. 

The  steam  bath  should  be  employed  in  case  of  uremia,  or  when  it 
is  not  available,  pilocarpine  should  be  given  hypodermatically.  The 
tendency  which  this  drug  is  said  to  possess  of  producing  or  at  any  rate 


Acidosis  227 

favoring  edema  of  the  lungs  is  against  it;  but  in  so  great  an  emergency 
as  uremic  coma  this  risk  may  be  taken.  The  hydrochlorate  is  the  best 
salt,  and  is  prescribed  in  doses  ten  to  fifteen  mgms.  Digitalis  is  of  use 
in  increasing  the  action  of  the  kidneys  and  heart.  Sparteine  is  also 
an  efficient  diuretic.  Sparteine  and  caffeine  given  together  are  at 
times  beneficial.     The  sulphate  is  employed  in  doses  of  30  to  1 20  mgms. 

Dry  cups  applied  over  the  loins  may  sometimes  be  of  service. 

Acidosis. — The  exact  symptoms  which  an  uncompensated  acidosis 
produces  in  any  given  individual  are  difl&cult,  if  not  impossible,  to 
define;  for  acidosis  is  present  only  in  connection  with,  or  as  a  result  of, 
more  or  less  grave  conditions.  It  can  be  expected,  however,  from 
results  of  experimental  procedures  on  controlled  isolated  phenomena, 
that  the  condition  will  be  productive  of  unfavorable  symptomatology. 
As  a  result  of  studies  on  large  numbers  of  operative  cases  with  due 
allowances  for  differences  in  individuals,  in  pathology,  and  in  operative 
procedures,  it  seems  fair  to  postulate  that  excessive  nausea  and  vomiting, 
gas  pains,  restlessness,  and  similar  symptoms,  are  often  accompanied 
by  uncompensated  acidosis.  The  type  of  patient  presenting  an  enlarged 
prostate  is  one  in  which  it  is  very  likely  to  occur.  The  individuals  are 
older,  have  usually  been  ill  for  a  considerable  time;  many,  if  not  most, 
have  some  form  of  nephritis  varying  in  grade,  together  with  arterioscle- 
rosis, and  a  damaged  myocardium.  The  mechanism  by  which  an  anes- 
thetic, ether  for  example,  changes  the  carbon  dioxide  of  the  blood  has 
been  studied  in  some  detail.  In  the  management  of  this  condition, 
prevention,  as  in  so  many  other  cases,  is  far  more  important  than 
cure.  A  general  .  scheme  which  has  given  satisfaction  is  as 
follows : 

At  the  same  time  that  blood  is  secured  for  the  determination  of  blood 
urea  and  other  substances,  enough  is  taken  with  proper  precautions 
to  determine  the  carbon  dioxide  combining  power  of  the  plasma.  The 
danger  point  is  50  cc.  of  carbon  dioxide  per  100  cc.  of  plasma.  Below 
this,  uncompensated  acidosis  is  said  to  exist.  The  decrease  in  the  carbon 
dioxide  combining  power  due  to  anesthesia  and  operation  has  been 
found  to  be  from  5  cc.  to  15  cc.  To  assure  that  the  safe  level  is  main- 
tained, it  is  well  to  give  alkali,  e.g.  sodium  bicarbonate,  to  those  indi- 
viduals showing  an  original  carbon  dioxide  combining  power  of  60  cc. 
carbon  dioxide,  or  less. 

The  necessary  dose  can  be  calculated  by  the  use  of  a  formula: 
I   gm.   of  sodium  bicarbonate  when  neutralized  will  yield  267  cc. 
of  carbon  dioxide. 


2  28  Treatment  of  Complications 

For  every  kilo  of  body  weight,  there  are  approximately  700  gm.  of 
fluid. 

Consequently,  the  amount  i  gm.  of  sodium  bicarbonate  will  increase 
the  carbon  dioxide  of  the  plasma  of  an  individual  weighing  i  kilo  per 

267 

100  cc,  will  be • 

7 

38? 
Consequently,  x  will  equal '    where   :*:   stands   for  the  desired 

increase  per  100  cc.  of  plasma,  g  the  number  of  grams  of  sodium  bicarb- 
onate, and  w  the  weight  of  the  individual  in  kilos. 

If,  therefore,  preliminary  analysis  has  shown  the  carbon  dioxide 
capacity  of  the  plasma  to  be  55  cc.  carbon  dioxide  per  100  cc,  and  it 
is  desired  to  increase  to  70  cc.  in  an  individual  weighing  75  kilos,  the 
amount  of  sodium  bicarbonate  necessary  will  be 

xw        15X75         ,      ^ 
g  =  ™g-  =       ^3       =  about  30  gm. 

The  maximum  effect  of  a  single  dose  by  mouth  is  reached  in  about 
two  hours;  but  it  can  be  given  in  hourly  doses  ending  about  two  hours 
before  operation. 

Rectal  administration  may  be  used  after  operation  either  inter- 
mittently or  constantly  in  4  per  cent,  solution. 

With  these  precautions,  trouble  from-  acidosis  per  se,  may  be 
entirely  avoided.  If  doubt  is  present  at  any  time,  determinations  can 
easily  and  quickly  be  made. 

Attention  is  here  also  called  to  too  much  alkali,  and  while  alkalosis 
has  not  received  the  same  amount  of  consideration  accorded  to  acidosis, 
it  perhaps  is  as  well  not  to  administer  too  much,  i.e.,  the  carbon  dioxide 
carrying  power  of  the  plasma  should  never  be  above  75  cc.  carbon 
dioxide  per  100  cc. 

REFERENCES  (CHAPTER  X) 

Bazy:  Presse  M6d.,  Paris,  1897,  i,  251;  Surgical  Disorders  of  the  Urinary  Organs,  London 

1887,  p.  417- 
Cabot:  Boston  Med.  and  Surg.  Jour.,  1903,  ii,  559. 

Caples,  B.  H. :  Catheter  Retainer,  Surg.,  Gynec.  and  Obstet,  1920,  xxx,  521, 
Chetwood:  Annals  of  Surgery,  1905,  Ixi,  497. 
Cullen,  G.  E.  and  Van  Slyke,  D.  D.:.A  Method  for  the  Determination  of  Carbon  Dioxide 

and  Carbonates  in  Solution.    Jour.  Biol.  Chem.,  191 7,  xxx,  347. 
Dittel:  Wien.  med.  Woch.,  1876,  26;  Nos.  22-25. 

Freyer:  Stricture  of  the  Urethra  and  Hypertrophy  of  the  Prostate,  2d  ed.,  London,  1902. 
Guyon:  Legons  sur  les  Maladies  des  Voies  Urinaires,  Paris,  1903,  4e.  ed.  i. 
Harrison:  The    Prevention   of   Stricture  and  of  Prostatic   Obstruction,  London,   1881; 

Surgical  Disorders  of  the  Urinary  Organs,  London,  1887,  p.  417. 


References  (Chapter  X)  229 

Moullin:  Enlargement  of  the  Prostate,  London,  1899. 

Palmer,  W.  W.  and  Van  Slyke,  D.  D.:  Relationship  between  Alkali  Retention  and  Akali 

Reserve  in  Normal  and  Pathological  Individuals.    Jour.  Biol.  Chem.,  i9i7,xxxii,  499. 
Reimann,  S.  P.:  The  Acid-Base  Regulatory  Mechanism  in  Anesthesia.    Am.  Jour.  Surg., 

2.  Suppl.  Anesth.,  1919,  xxxii,  86. 
Reimann,  S.  P.,  and  Bloom,  G.  H.:  The  Decreased  Plasma  Bicarbonate  during  Anesthesia 

and  Its  Cause.    Jour.  Biol.  Chem.,  1918,  xxxvi,  211. 
Ruggles:  Quoted  by  Keyes:  Urology,  191 7,  p.  29. 
Senn:  Practical  Surgery,  Phila.,  1902. 

Socin  and  Burckhardt:  Die  Verletzungen  u.  Krankheiten  der  Prostata,  Stuttgart,  1902. 
Van  Slyke,  D.  D.,  and  CuUen,  G.  E.:  The  Bicarbonate  Concentration  of  the  Blood  Plasma, 

etc.    Jour.  Biol.  Chem.,  191 7,  xxx,  289. 
Watson:  Boston  Med.  and  Surg.  Jour.,  1895,  ii,  154. 
Wolff:  Deutsche  med.  Woch.,  1899. 
Young:  Jour.  Amer.  Med.  Ass.,  1913,  Ix,  253. 


CHAPTER  XI 

PALLIATIVE      OPERATIONS      INCLUDING      CYSTOSTOMY, 

YOUNG'S  PUNCH   OPERATION,   CHETWOOD'S 

OPERATION,  AND  FULGURATION 

The  history  of  the  development  of  the  operations  of  suprapubic  and 
perineal  cystostomy  by  simple  puncture  has  been  dealt  with  elsewhere. 
Perineal  puncture  has  been  universally  abandoned,  while  tapping  the 
bladder  suprapubically  is  merely  a  palliative  measure  for  use  in  cases 
in  which  the  urethra  is  impassable,  and  where  other  means  of  relieving 
the  retention  are  not  available. 

Lower,  of  Cleveland,  has  suggested  the  use  of  the  trocar  and  cannula 
to  take  the  place  of  the  more  formal  cystostomy,  not  only  for  the  purpose 
of  providing  suprapubic  drainage  in  inoperable  cases,  but  also  as  the 
initial  step  in  the  two-stage  operation  of  prostatectomy  in  certain 
circumstances  that  preclude  a  more  radical  procedure.  The  simplicity 
of  this  method  and  the  satisfactory  results  that  follow  its  use  should 
make  it,  according  to  Lower,  the  method  of  choice  in  selected  cases. 

The  Trocar  and  Cannula  Method  of  Lower. — Lower  has  recently  called 


Fig.  67. — Trocar   and  Cannula  with  Metal  cellar. — {Lower,  Urol,  and  Cutan.  Rev., 

1914,  xviii,  6.) 

attention  to  a  method  of  draining  the  bladder  by  means  of  the  trocar 
and  cannula  which  undoubtedly  has  many  advantages  over  simple 
puncture.  The  senior  author  used  this  same  method  many  years  ago 
before  the  operation  of  cystostomy  was  fully  perfected ;  he  believes  that 
it  has  a  place  in  the  treatment  of  certain  desperate  cases  of  enlarged 

230 


Gibson's   Operation 


231 


prostate  with  acute  retention  in  which  almost  any  operative  interference 
would  be  attended  with  grave  danger.  The  method  provides  not  only 
for  reHef  in  cases  in  which  reUef  is  urgently  demanded,  but  provides 
in  addition  for  permanent  drainage  of  the  bladder.  It  may  be  used  as 
a  substitute  for  the  ordinary  cystostomy  and  has  the  advantage  over 
simple  puncture  in  that  it  practically  eliminates  the  danger  of  urinary 
infiltration  in  the  abdominal  parietes. 

Lower  states  that  the  trocar  and 
cannula  method  often  proves  to  be 
a  more  comfortable  way  of  providing 
bladder  drainage  as  a  preliminary  to 
prostatectomy  than  the  use  of  the 
catheter  per  urethram.  We  cannot 
see  the  advantage  of  this  method 
over  formal  cystostomy  except  in 
cases  of  acute  urinary  retention  in 
which  catheterization  is  impossible, 
and  in  which  even  so  slight  an 
operation  as  cystostomy  under  local 
anesthesia  would  be  attended  by 
grave  danger. 

The  uncertainty  of  the  location 
of  the  opening  in  the  bladder,  the 
small  size  of  the  fistula  which  pre- 
vents digital  exploration  of  the 
bladder,  the  fact  that  it  provides  in- 
adequate drainage  and  renders  the 
subsequent  removal  of  the  prostate  difficult,  are  the  great  disadvantages 
of  the  trocar  and  cannula  method. 

This  method  may  be  used  to  advantage,  however,  in  establishing 
a  urinary  fistula  for  the  treatment  of  certain  inoperable  cases. 

Technique. — The  trocar  and  cannula  are  forced  into  the  bladder  a  ta 
point  sufficiently  distant  from  the  pubis  to  avoid  puncture  of  the  plexus 
of  veins  which  lies  just  behind  the  pubic  bone.  A  local  anesthetic  may  be 
used  but  is  ot  essnential.  The  bladder  must  be  sufficiently  distended 
to  displace  the  peritoneum  out  of  harm's  way.  The  trocar  is  withdrawn 
leaving  the  cannula  in  place  and  through  the  latter  a  sterile.  No.  14  (F.), 
soft  rubber  catheter  is  inserted  into  the  bladder  cavity.  The  cannula 
is  then  withdrawn  over  the  catheter  which  is  allowed  to  remain  in  the 
bladder. 


Fig.  68. — ^Lower's  Trocar  and 
Cannula  Method. 

Step  I.  Trocar  introduced  into 
Bladder. — {W.  E.  Lower,  Urologtcal  and 
Cutaneous  Review.) 


232 


Palliative  Operations 


The  after-treatment  is  essentially  the  same  as  with  other  forms 
of  suprapubic  drainage  operations.  In  the  subsequent  removal 
of  the  prostate  it  is  necessary  greatly  to  enlarge  the  opening  and  in  so 
doing  it  must  be  remembered  that  the  original  opening  is  located  at  a 
point  more  distant  from  the  summit  of  the  bladder  than  is  the  case 
with  the  ordinary  cystostomy  wound. 


Fig.  69. — ^Lower's  Trocar  and 
Cannula  Method. 

Step  2.  Catheter  Introduced  into 
bladder  through  the  Cannula. — {Uro- 
logical  and  Cutaneous  Review.) 


Fig.  70. — ^Lower's  Trocar  and 
Cannula  Method. 

Step  3.  Cannula  withdrawn  leaving 
Catheter  in  Bladder. — {Urological  and 
Cutaneous  Review.) 


In  cases  in  which  prostatectomy  is  contraindicated,  and  in  which 
permanent  drainage  is  necessary,  the  fistulous  tract  may  be  fitted  with 
a  metal  cannula  with  urinal  attachment,  or  the  cannula  may 
be  fitted  with  a  cork  which  can  be  removed  when  the  desire  to  uri- 
nate is  felt. 

Gibson's  Operation. — The  formation  of  a  bladder  valve,  as  devised 
by  Gibson,  for  the  treatment  of  inoperable  carcinoma  of  the  bladder 
and  prostate  is  likewise  useful  in  a  very  limited  group  of  patients  with 
benign  prostatic  hypertrophy.  This  group  includes  only  those  cases 
in  which  the  absolute  impossibility  of  subsequent  removal  of  the 
prostate  can  be  predetermined.     This  is  a  necessarily  limited  group, 


Gibson's  Operation 


233 


because  one  can  rarely  be  sure,  however  desperate  the  condition  of  the 
patient  may  be  before  drainage  of  the  bladder  is  provided,  that  the 
vital  functions  Avill  not  be  sufficiently  restored  as  the  result  of  such 
drainage  to  justify  the  attempt  to  remove  the  prostate  at  some  later 
time.  The  Gibson  operation  is  applicable  only  to  patients  with  a 
reasonably  large  bladder  capacity.  The  operation  is  performed  as 
follows : 

The  bladder  is  exposed  suprapubically  in  the  usual  manner.  An 
incision  large  enough  to  admit  a  catheter.  No.  30  French  scale,  is  then 
made  into  the  bladder  at  its  mid- 
point. A  No.  30  soft  rubber 
catheter  is  inserted  through  the 
incisional  opening  into  the  bladder 
and  anchored  to  the  margins  of  the 
incision  which  is  then  closed  above 
and  below  the  catheter.  Two 
Lembert  sutures  are  now  passed 
through  the  bladder  wall  above 
and  below  the  catheter,  these 
sutures  being  so  placed  that  an 
infolding  of  the  bladder  wall  will 
occur  when  they  are  tied;  the  por- 
tion of  the  bladder  wall  between 
these  sutures  is  thus  invaginated 
into  the  bladder  cavity,  carrying 
the  catheter  with  it. 

Additional    Lembert     sutures 
are   inserted    and   tied    so    that 

further  invagination  of  the  bladder  wall  is  produced  with  the  result 
that  a  valve-like  fold  is  formed.  The  suture  material  recommended 
is  No.  2  chromic  catgut.  The  abdominal  wound  is  closed  with 
through  and  through  sutures  of  silkworm  gut.  The  steps  in  the  opera- 
tion are  clearly  shown  in  the  accompanying  illustrations. 

The  after-treatment  consists  in  the  removal  of  the  catheter  as  soon  as 
absorption  of  the  retention  sutures  has  occurred,  usually  at  the  end  of 
the  first  week,  with  the  substitution  of  a  No.  23,  soft  rubber  catheter. 
This  is  replaced  about  the  end  of  the  second  week  by  a  No.  20  catheter; 
with  the  contraction  of  the  fistula  to  this  size  the  bladder  valve  becomes 
retentive. 

The  subsequent  care  of  the  fistula  is  simply  a  matter  of  cleanliness 


Fig.  71 


Lower's  Trocar  and  Cannula 
Method. 
Step  4.     Catheter    fixed   in   position. 
(JJrological  and    Cutaneous  Review.) 


234 


Palliative  Operations 


Fig.  72. — Gibson's  Operation. 
Step  I.     (Ramon  Giiiteras,  A  Text-book  of  Urology,  D.  Appldon  and  Co.) 


Fig.  73. — Gibson's  Operation. 
Step  2.     {Ramon  Guiteras,  A  Text-book  of  Urology,  D.  Appleton  and  Co.) 


Gibson's  Operation 


235 


except  if  it  shows  a  tendency  to  close  in  which  event  dilatation  is  neces- 
sary. The  Oberlander  dilator  is  recommended  for  this  purpose  athough 
straight,  olivary  tipped  urethral  bougies  of  the  woven  variety  may  be 
used  with  equal  satisfaction. 


Fig.  74. — Gibsons  Operation. 
Step  3.     {Ramon  GuUeras,  A  Text-book  of  Urology,  D.  Appleton  and  Co). 

The  bladder  valve  permits  the  easy  removal  of  residual  urine  per 
catheter.  Leakage  of  urine  does  not  occur,  and  the  patient  can  void 
normally  if  the  urethra  is  patulous.  If,  for  any  reason,  the  use  of  the 
normal  channel  is  undesirable  the  bladder  may  be  emptied  at  regular 
intervals  by  simply  inserting  a  soft  rubber  catheter  through  the 
valvular  opening. 

The  Gibson  operation  is,  as  we  have  already  stated,  rarely  indicated 
in  cases  of  benign  prostatic  hypertrophy,  but  it  is  enimently  suited  to 
that  small  group  of  cases  in  which  prostatectomy  is  contra-indicated 
and  in  which  a  false  urethra  must  be  provided.  It  is  not  to  be  employed 
as  a  substitute  for  catheterism,  but  only  in  cases  where  the  latter  has 
been  tried  unsuccessfully,  where  prostatectomy  is  out  of  the  question, 
and  where  the  valve  operation  seems  to  be  superior  to  the  ordinary 
suprapubic  operation  of  cystostomy  as  a  means  of  providing  the  neces- 
sary false  channel  for  evacuating  the  urine. 


236 


Palliative  Operation 


INTRA-URETHRAL    OPERATIONS   FOR   THE   RELIEF   OF 
OBSTRUCTIONS  AT  THE  VESICAL  OUTLET 


The  development  of  urethral  instruments  and  the  technique  of 
their  employment  for  the  relief  of  obstructions  at  the  vesical  outlet 
are  discussed  at  some  length  in  Chapter  I.  There  will  be  found  descrip- 
tions of  some  of  the  instruments  and  methods  that  are  now  employed, 
in  a  modified  form  it  is  true,  but  still  the  same  in  principle,  for  the 
removal,  or  destruction  of  various  obstructing  factors  in  this  locality. 

Much  confusion  characterizes  the  attempts  made  to  separate  these 
conditions  into  pathological 
entities  separate  and  distinct  from 
diseases  of  the  prostate  gland; 
clinically  they  give  rise  to  a 
syndrome  that  is  identical  with 
that  arising  from  true  prostatic 
hypertrophy. 

The  expert  cystoscopist  can 
form  a  rather  precise  idea  of  the 
nature  of  the  lesion  in  any  given 
case,  and  of  the  method  of  treat- 
ment particularly  adapted  to  its 
removal;  the  average  surgeon, 
however,  must  rest  content  with 
the  knowledge  that  an  obstructive 
lesion  exists  which  is  organic  but 
not  neoplastic  in  nature,  and 
probably  not  of   prostatic  origin, 

or  at  least  not  associated  with  generalized  benign  hypertrophy  of  the 
prostate  gland.  He  will  realize  also  that  prostatectomy  may  or  may 
not  be  necessary  to  remove  the  obstruction. 

The  diagnosis  and  pathological  description  of  the  conditions  to 
which  we  now  refer  are  given  elsewhere,  suffice  it  to  say  here  that  they 
are  variously  known  under  the  terms,  "contracture  of  the  vesical  neck, 
median  bar  formation,  submucous  fibrosis,  atrophy  of  the  prostate, 
prostatism  sans  prostate,  hypertrophy  of  the  subcervical  (Albarran's) 
glands,  hypertrophy  of  the  subtrigonal  glands,  isolated  fibro-adenomata 
of  the  prostate  gland,  median  lobe  enlargements,  etc." 

Practically  all  of  the  modern  instruments  used  in  the  treatment  of 
the  aforementioned  conditions  are,  in  principle,  quite  similiar  to  others 


Fig.  75. — Gibson's  Operation. 

Diagram  showing  the  Infolded  Bladder 

Wall  forming  a  Valve. 


Intra-Urethral  Operations  237 

which  have  long  been  discarded.  Thus  the  punch  devised  by  Young 
is  very  similar  to  Mercier's  prostatectome,  a  picture  of  which  is  shown 
in  Chapter  I.  Mercier's  instrument  was  introduced  into  surgery  in 
1839  but  was  soon  forgotten.  This  antedated  the  modern  cystoscope 
by  many  years  and  doubtless  the  improper  selection  of  cases  explained 
in  part  the  failure  of  Mercier's  method,  which  enjoyed  but  a  brief 
popularity. 

Chetwood's  galvano-cautery  is  in  principle  the  same  as  the  galvano- 
cauterization  of  Bottini,  to  which  however  it  is  vastly  superior. 

Finally,  the  high-frequency  spark  operation  introduced  by  Bugbee 
is  a  refinement  of  the  method  advocated  by  Wossidlo;  the  latter 
attempted,  but  without  much  success,  to  combine  in  one  instrument 
the  cystoscope  with  the  galvano-caustic  incisior,  and  to  this  instrument 
he  gave  the  name  of  "Incision  Skystoskop. " 

The  trend  of  modern  surgery  in  the  treatment  of  these  cases  is 
undoubtedly  toward  suprapubic  operation  notwithstanding  the  claims 
made  by  the  advocates  of  the  palliative  forms  of  treatment.  We 
believe  that  the  prostate  should  not  be  disturbed  in  cases  where  it  in 
no  way  contributes  to  the  existing  obstruction  at  the  vesical  outlet. 
But  we  believe  also  that  in  the  hands  of  the  average  surgeon,  and  this 
includes  the  great  majority  of  specialists,  better  results  will  be  obtained 
by  opening  the  bladder  suprapubically  and  removing  the  obstructing 
element  with  the  knife  or  rongeur  than  with  from  any  form  of  intra- 
urethral  operation. 

In  certain  cases  we  have  performed  perineal  prostatectomy  but  the 
results  were  not  entirely  satisfactory;  this  applies  especially  to  those 
cases  in  which  there  is  a  widespread  fibrosis  in  the  region  of  the  vesical 
neck  associated  perhaps  with  interstitial  cystitis.  In  the  treatment  of 
these  and  other  cases  in  which  we  formerly  used  the  Bottini  incisor,  we 
now  prefer  the  suprapubic  operation  with  removal  of  the  obstructive 
elements  by  means  of  the  rongeur  forceps,  scalpel,  or  scissors.  The 
choice  of  the  method  to  be  employed  is  made  after  the  bladder  is  opened, 
and  in  many  instances  the  final  judgment  is  for  prostatectomy  in 
cases  in  which  simple  excision  of  a  median  bar  or  other  extra-prostatic 
lesion  seemed  to  be  indicated  by  cystoscopic  examination.  It  is  not 
good  surgery,  in  our  judgment,  to  do  a  punch  operation  for  the  purpose 
of  providing  temporary  relief  from  a  condition  that  will  later  demand  a 
radical  operation.  The  punch  operation  may  be  used  to  advantage  in 
cases  in  which  under  more  favorable  circumstances  prostatectomy 
would  be  indicated  and,  judging  from  the  results  of  this  operation  as 


238  Palliative  Operations 

reported  by  Young  and  others,  a  great  deal  of  good  may  be  accomplished, 
even  though  a  complete  cure  is  not  obtained. 

We  prefer,  as  previously  mentioned,  the  suprapubic  operation  with 
excision  of  the  obstructing  element  and  would  limit  the  use  of  intra- 
urethral  operations  to  those  cases  in  which  the  more  radical  form  of 
treatment  is  for  any  reason  contra-indicated. 

Electric  Cauterization  of  Obstructions  at  the  Vesical  Outlet  by  means  of 
the  high  frequency  current  has  been  given  some  prominence  lately  by 
Bugbee  and  his  followers.  Originally  this  method  was  said  to  be 
applicable  to  the  same  class  of  cases  as  the  Young  punch  operation. 
More  recently,  however,  Bugbee  has  expressed  the  view  that  the  high- 
frequency  spark  is  inferior  to  the  Young  punch  since  it  is  difficult  to  burn 
deeply  into  the  products  of  inflammation  surrounding  the  outlet  of  the 
bladder.  The  fulgurating  or  high-frequency  current  may  perhaps  be 
useful  as  a  palliative  if  not  curative  method  of  treatment  in  the  early 
stages  of  subcervical  glandular  hyperplasia.  It  may  also  prove  to  be 
an  efficient  means  of  relieving  chronic  congestive  states  of  the  mucosa 
in  this  region,  but  little  can  be  hoped  for  in  the  treatment  of  true  prostatic 
hypertrophy  or  submucous  fibrosis.  The  high-frequency  spark  was 
suggested  by  Bugbee  for  the  destruction  of  prostatic  nodules  remaining 
about  the  vesical  neck  after  incomplete  prostatectomy,  and  it  is  stated 
that  partial  relief  was  obtained  by  fulguration  in  these  cases.  An 
incomplete  prostatectomy  which  fails  to  relieve  the  patient's  sufferings 
is  in  our  judgement  a  very  definite  indication  for  re-operation,  provided 
the  condition  is  not  a  malignant  one.  In  the  cases  of  this  kind  that  we 
have  re-operated,  the  condition  of  the  tissues  in  the  region  of  the  outlet 
of  the  bladder  was  such  that  radical  operation  was  obviously  necessary. 
Cases  have  been  reported,  however,  in  which  remaining  nodules  of 
prostatic  tissue  and  obstructing  folds  of  mucous  membrane  were 
successfully  removed  with  the  Young  punch. 

Technique. — The  nature  and  location  of  the  obstructive  lesion  is 
determined  in  preliminary  cystoscopic  studies,  for  which  the  cysto- 
urethroscope  is  the  most  satisfactory  instrument  both  for  examination 
and  treatment. . 

Having  decided  upon  the  nature  of  the  lesion  and  the  location  of 
the  areas  where  the  cauterization  is  to  be  applied,  the  cystoscope  is 
introduced  into  the  bladder  cavity.  With  the  beak  of  the  instrument 
in  the  partly  distended  bladder,  the  electric  wire  is  introduced  until 
it  appears  in  the  field  and  is  then  further  advanced  until  at  least  one 
half  inch  projects  from  the  window  of  the  cystoscope.     The  irrigating 


Young's  Punch  Operation  239 

fluid  is  then  permitted  to  flow  slowly  into  the  bladder  and  at  the  same 
time  the  cystoscope  and  the  electric  wire  are  slowly  withdrawn  until 
the  area  to  be  treated  appears  within  the  field  of  vision.  If  this  is  on 
the  floor  of  the  sphincteric  margin,  the  instrument  is  held  against  the 
roof  of  the  urethra  by  depressing  its  ocular  end,  and  a  similar  procedure 
will  aid  in  bringing  other  areas  more  clearly  into  view. 

When  the  obstructive  lesion  has  appeared  in  the  field,  the  instrument 
is  further  withdrawn,  but  only  for  a  very  short  distance,  and  the 
deflector  is  turned,  whereupon  the  tip  of  the  wire  will  be  seen  to  touch 
the  diseased  area. 

Some  cystoscopists  advise  that  the  lesion  be  located  before  the 
wire  is  made  to  emerge  from  the  sheath  of  the  cystoscope,  but  we  have 
found  it  much  easier  to  place  the  wire  in  the  proper  position  with  the 
technique  just  described. 

The  Oudin  (unipolar),  or  the  d'Arsonval  (bipolar),  current  is  used 
and  the  spark  is  applied  for  variable  periods  of  time,  usually  one  minute, 
depending  upon  the  strength  of  the  current  and  the  depth  of  the  tissues 
to  be  destroyed.  Several  weeks  are  required  for  the  sloughs  to  separate. 
The  frequency  of  the  treatments  must  be  guided  by  the  tolerance  of  the 
individual  patient  to  instrumentation.  As  a  rule,  it  is  unwise  to 
repeat  the  cauterization  until  the  slough  caused  by  the  first  treatment 
has  come  away  and  the  ulceration  has  begun  to  heal.  Repeated  cau- 
terizations are  usually  necessary  before  definite  improvement  is  noted. 

Young's  Punch  Operation.^ — Under  the  title  "A  New  Procedure 
(Punch  Operation)  for  Small  Prostatic  Bars  and  Contractures  of  the 
Prostatic  Orifice,"  Young  of  Baltimore,  in  1913,  presented  to  the 
profession  a  new  method  of  treatment  for  the  particular  groups  of 
cases  now  under  discussion. 

This  method  is,  in  principle,  that  described  many  years  ago  by 
Mercier,  but  it  remained  for  Young  not  only  to  perfect  the  instrument, 
but  to  clearly  define  the  group  of  patients  suffering  from  obstructions 
at  the  vesical  neck  to  which  the  punch  operation  is  applicable.  He 
further  subdivided  these  cases  into  groups,  showing  the  method  of 
applying  the  punch  in  each  group  and  the  results  that  might  be  expected 
to  follow. 

The  punch  operation  has  met  with  more  general  acceptance  than 
any  of  the  other  intra-urethral  methods  of  treatment,  if  we  may 
judge  from  the  reports  in  the  literature,  although  it  has  by  no  means 
met  with  the  enthusiastic  support  of  the  large  majority  of  surgeons. 
We  have  had  no  experience  with  the  method,  prefering  instead  the 


240  Palliative  Operations 

suprapubic  operation  in  those  cases  in  which  the  punch  operation 
might  be  thought  to  be  appropriate.  The  following  remarks  are  based 
entirely  on  data  contained  in  the  Hterature. 

At  the  time  of  the  first  report  (1913),  Young  had  performed  the 
operation  in  approximately  one  hundred  cases,  which  number  has  been 
considerably  increased  since  then.  The  first  group  of  cases  were 
classified  as  follows: 

(a)  Median  bar  obstruction 51 

(b)  Prostatic  bar  or  contracture  with  diverticulae S 

(c)  Prostatic  bar  or  contracture  with  calculus 11 

(d)  Prostatectomy  cases  with  incomplete  results 20 

(e)  Median  bar  with  trigonal  elevation  and  obstruction 3 

(/)  Spinal  cases  wiih  large  amounts  of  residual  urine  (associated 

with  median  bar) 3 

(g)  Obstruction  associated  with  carcinoma  (vesical  or  prostatic)  .  .     9 

Results.  Class  (a)  51  cases. — The  results  were  entirely  satisfactory, 
there  were  no  fatalities  and  the  only  immediate  post-operative  complica- 
tion was  hemorrhage.  This  was  never  alarming  however  and  never 
necessitated  opening  the  bladder  to  control  it.  The  end-results  were 
likewise  satisfactory. 

Class  (b)  5  cases. — Young's  experience  in  this  group  of  patients 
led  him  to  remark  that  simple  removal  of  the  obstruction  either  by 
prostatectomy,  or  by  the  punch  operation  relieved  the  patient  and  that 
excision  of  the  diverticulum  is  unnecessery  except  when  the  ureter  is 
interfered  with.  In  our  experience  the  removal  of  the  obstruction  does 
not  greatly  benefit  the  patient  with  a  large  diverticulum.  If  such 
patients  can  be  kept  in  comparative  comfort  by  palliative  means  it  is 
better,  in  our  judgment,  to  withhold  operation  even  though  the  ureter 
is  drawn  into  the  sac  of  the  diverticulum. 

Class  (c)  II  cases. — Young  is  particularly  enthusiastic  over  the 
results  of  the  punch  operation  in  cases  of  median  bar  complicated  by 
stone.  The  stone  is  crushed  and  removed,  and  following  the  litholapaxy 
the  median  bar  is  punched  out  thus  removing  the  cause  of  stone  for- 
mation in  this  particular  group.  All  of  the  patients  were  cured  and  none 
had  a  recurrence  of  the  stones. 

Class  (d)  20  cases. — This  most  interesting  group  of  cases,  the  details 
of  which  are  described  in  the  "Transactions"  of  the  Section  on  Genito- 
urinary Diseases  of  the  American  Medical  Association,  191 2,  were 
operated  upon  with  the  "punch"  and  with  most  gratifying  results. 
The  t3rpe  of  obstruction  and  its  location  with  reference  to  the  various 
segments  in  the  circumference  of  the  vesical  outlet  was  by  no  means 


Young's  Punch  Operation  241 

constant.  In  some  instances  the  cystoscopic  rongeur  was  employed  to 
remove  pedunculated  or  rounded  nodules  followed  by  the  removal  of 
the  base  of  such  lobe  or  nodule  with  the  punch. 

Class  (e)  3  cases. — This  group  is  of  interest  in  that  attention  is 
drawn  for  the  first  time  to  trigonal  elevation  asacauseof  urinary  obstruc- 
tion. 

Class  (J)  3  cases. — In  only  one  of  these  cases  was  the  removal  of  an 
obstructing  median  bar  followed  by  a  restoration  of  bladder  function. 

Class  (g)  9  cases. — The  punch  operation  is  advised  only  as  a  pallia- 
tive measure,  the  purpose  of  which  is  to  remove  a  median  bar  obstruc- 
tion complicating  an  otherwise  inoperable  carcinoma  of  the  prostate. 
Since  the  publication  of  this  preliminary  report  the  punch  has  been  used 
more  extensively  in  this  class  of  patients  and  with  good  results.  It 
should  not  be  used,  however,  to  the  exclusion  of  radium  and  other  mea- 
sures that  may  hold  the  disease  in  check. 

Since  the  appearance  of  Young's  report  the  punch  operation  has 
been  used  by  many  surgeons  and  the  reports  are  on  the  whole  encourag- 
ing, although  no  one  seems  to  have  had  extensive  experience  with  the 
method  except  its  originator.  Post-operative  bleeding  has  been  observed 
and  in  some  instances  this  necessitated  suprapubic  cystostomy.  Cun- 
ningham suggests  the  use  of  a  dePezzer  catheter  after  the  punch 
operation.  He  claims  that  the  button-like  end  of  the  catheter  will 
exert  sufficient  pressure  on  the  wound  to  control  all  dangerous  bleeding. 
Cunningham  states  that  he  found  it  necessary  on  several  occasions, 
before  adopting  the  retention  catheter,  to  do  an  external  urethrotomy 
to  control  the  bleeding.  The  introduction  of  a  larger  catheter  through 
the  perineal  wound  than  could  be  introduced  per  urdhram  effectually 
controlled  the  hemorrhage. 

Young  originally  advocated  the  use  of  a  two-way  catheter  intro- 
duced through  the  urethra  with  continuous  irrigation  of  the  bladder 
after  the  punch  operation,  but  in  a  more  recent  article  he  states  that  the 
hemorrhage  can  be  controlled  by  the  introduction  of  a  single  catheter 
the  end  of  which  is  coated  with  cephalin,  a  hemostatic  agent  described 
by  Howell. 

Notwithstanding  the  interest  in  this  subject  that  Young's  work  has 
stimulated,  the  literature  contains  comparatively  few  references  to  the 
punch  operation.  In  practically  all  instances  such  references  as  are 
available  refer  to  only  a  few  cases.  Young  seems  not  to  have  changed 
his  opinion  regarding  the  merits  of  the  operation,  and  it  is  interesting  to 
review  the  later  reports  from  his  cUnic.     Among  these  may  be  quoted 

16 


242  Palliative  Operations 

that  of  H.  C.  Cecil,  who  gave  a  resume  of  the  results  of  Young's  opera- 
tions before  the  Philadelphia  Academy  of  Surgery  in  191 7.  This 
report  includes  the  late  results  in  128  cases,  tabulated  as  follows: 

70  patients Cured 

13  patients 90  per  cent,  improved 

16  patients 75  per  cent,  improved 

13  patients 50  per  cent,  improved 

3  patients 25  per  cent,  improved 

13  patients Not  improved 

In  the  thirteen  cases  in  which  no  improvement  was  noted  after  the 
punch  operation,  the  symptoms  were  due  to  a  contracted  bladder.  All  of 
these  cases  showed  median  bars  on  cystoscopic  examination,  but  the 
associated  pathology  in  the  bladder  wall  was  such  that  the  punch  opera- 
tion failed  to  effect  a  cure. 


Fig.  76. — Young's  Urethroscopic  Median  Bar  Excisor. 

In  a  detailed  description  of  a  very  remarkable  case.  Young  shows 
the  possibilities  of  treatment  with  the  combined  use  of  radium,  fulgura- 
tion,  and  the  punch  in  desperate  cases  of  enlarged  prostate.  This 
report  is  interesting  in  that  it  shows  how  much  can  be  done  to  relieve 
the  sufferings  of  certain  individuals  in  whom  prostatectomy  is  absolutely 
contraindicated  on  account  of  cardiac  or  other  organic  defects. 

Technique. — The  instrument  consists  of  two  tubes  which  fit  one  with- 
in the  other,  and  an  obturator.  The  inner  tube  is  hollow  and  has  a  sharp 
edge  which  serves  as  a  knife  to  punch  out  any  tissue  that  may  appear 
through  the  fenestrum  of  the  outer  tube  or  sheath.  The  latter  is  pro- 
vided with  an  opening  on  its  convexity  near  the  inner  or  bladder 
extremity.  The  latter  end  is  curved  like  a  coude  catheter.  The  outer 
end  of  the  sheath  is  provided  with  a  Ught-carrying  attachment  similar 
to  that  of  the  Young  urethroscope. 


Young's  Median,  Bar  Excision  243 

The  use  of  the  urethroscopic  Hght  is  unnecessary  for  locating  the 
part  to  be  removed;  this  should  be  done  by  cystoscopic  examination 
before  the  operation  is  attempted.  The  exact  position  of  the  part  to  be 
operated  upon  being  known,  it  is  a  simple  matter  to  engage  it  in  the 
fenestrum  of  the  sheath  by  pushing  the  instrument  into  the  bladder 
cavity  whereupon  urine  will  escape;  by  withdrawing  the  instrument 
until  the  flow  of  urine  suddenly  stops  the  bar  is  brought  into  the  fenes- 


""^^^^l 

^^S^^m 

\ 

'y3|H[|^^^^^^^^^^^^^^^^^^^^^H 

^^w^^^ 

Fig.  77. — Median  bar  excisor  or  punch  instrument  introduced  into  the  bladder;  cutting 
inner  tube  withdrawn  allowing  fluid  to  escape,  showing  that  the  instrument  is  in  the  bladder. 
{HughH.  Young,  Annals  of  Stir  gery,  191 7,  Ixxv,  i.) 

trum  and  it  is  then  a  simple  matter  to  insert  the  inner  tube  and  punch 
out  the  desired  amount  of  tissue.  The  procedure  may  have  to  be 
repeated  several  times  before  all  of  the  obstructing  tissue  is  removed. 
This  procedure  calls  for  familiarity  with  urethral  instrumentation,  but 
if  the  operator  is  possessed  of  sufficient  skill  to  enable  him  to  locate  and 
recognize  the  bar  and  to  bring  it  into  the  fenestrum  under  the  guidance 
of  the  eye  aided  by  reflected  light,  he  is  equally  capable  of  accomplish- 
ing this  by  the  manipulations  just  described. 

The  operation  is  performed  with  local  anesthesia  and  with  the 
bladder  filled  with  a  mild  antiseptic  solution. 

When  the  bar  is  engaged  in  the  instrument,  the  inner  tube  is  pushed 
home,  thus  excising  in  one  piece  the  tissues  contained  within  the  window 
of  the  tube.  The  inner  tube  contains  the  piece  of  tissue,  which  is 
removed  with  forceps.  Young  advises  the  removal  of  several  additional 
segments  of  tissue  at  the  lateral  extremities  of  the  bar. 


244 


Palliative  Operations 


The  tissues  to  be  excised  may  occupy  the  anterior  or  lateral  portions 
of  the  vesical  outlet  and  the  position  of  the  instrument  must  be  varied 
accordingly. 

The  after-treatment  consists  of  drainage  of  the  bladder  by  a  catheter 
of  large  calibre  and  lavage  of  the  bladder  to  remove  blood  clots.  As 
previously  stated,  Young  recommends  that  the  end  of  the  catheter  be 
coated  with  cephalin.  This  substance  is  dissolved  in  a  small  quantity 
of  ether  and  the  solution  is  slowly  poured  over  the  end  of  the  catheter 
so  that  the  ether  will  evaporate  leaving  a  coating  of  cephalin  on  the 
instrument. 


Fig.  78. — Instrument  withdrawn  until  the  Median  Bar  is  Entrapped  in  the 
Fenestra  when  the  Inner  Cutting  Tube  is  Quickly  Pushed  Inward  to  Excise  the 
Bar. — {Hugh  H.  Young,  Annals  of  Surgery.) 

If  blood  clots  collect  in  the  bladder  cavity  they  must  be  re- 
moved by  aspiration  with  a  Valentine  or  other  suitable  syringe.  The 
catheter  may  be  removed  within  twenty-four  hours  if  the  bleeding 
has   ceased.     Subsequent  dilatation   of   the   urethra  is   unnecessary. 

Caulk  has  recently  introduced  a  modified  Young's  punch  in  which  a 
cautery  blade  takes  the  place  of  the  cutting  edge  of  the  inner  sheath 
of  the  Young  instrument.  The  originator  of  this  instrument  reports 
a  series  of  fifty  cases  in  which  the  obstruction  was  relieved  by  electro- 
coagulation, with  uniformly  good  results.  The  danger  of  hemorrhage 
after  electro-coagulation  are  said  to  be  nil. 


Chetwood's  Galvano-Prostatomy  245 

Perineal  Galvano-prostatomy  (Chetwood). — Galvano-cauterization  of 
the  vesical  neck  through  a  perineal  urethrotomy  wound  (Chetwood's 
operation)  is  a  modification  of  the  Bottini  operation,  the  latter  being 


Fig.  79. — Cutting  Tube  Half  Way  through  the  Bar.— (Hugh  H.  Young,  Annals  of 

Surgery.) 

also   a   galvano-prostatomy  but  is   performed   through   the   urethra 
without  a  perineal  incision. 

Both  operations  have  been  abandoned  by  the  majority  of  operators 


« 
Fig.  80. — Cutting  Tube  pushed  Home,  Completely  Excising  the  Bar. — {Hugh  H. 

Young,  Annals  of  Surgery.) 

and  especially  is  this  true  of  the  Bottini  method.  Chetwood  and  a 
limited  number  of  other  surgeons  hold  to  the  opinion  that  galvano- 
cauterization  offers  the  best  means  of  treating  contractures  or  strict- 


246  Palliative  Operations 

ures  of  the  vesical  neck,  which  conditions  may  or  may  not  be  a  part  of, 
or  arise  subsequent  to,  primary  disease  in  the  prostate  gland. 

The  pathology  of  this  condition,  according  to  Chetwood,  is  not  that 
of  fibrosis  alone,  but  one  associated  with  what  he  terms  circular  or 
concentric  hypertrophy  of  glandular  prostatic  elements  which  normally 
lie  in  juxtaposition  with  the  sphincteric  area  of  the  bladder  outlet. 

Whether  or  not  this  is  a  true  conception  of  the  pathological  change, 
the  fact  remains  that  there  is  a  considerable  group  of  cases  in  which 
an  obstruction  to  urination  exists  at  the  bladder  outlet  which  cannot 


Fig.  81. — The  Excised  Bar  Grasped  in  Tube  with  Intraurethral  Forceps  Previous 
TO  Removal. — {Hugh  H.  Young,  Annals  of  Surgery.) 

be  relieved  satisfactorily  by  removal  of  the  prostate.  To  this  group 
Chetwood  believes  the  operation  of  galvano-cauterization  is  eminently 
suited.  It  will  suffice  to  remind  the  reader  at  this  time  that  we  ad- 
vocate suprapubic  exploration  of  the  bladder  in  this  group  of  cases, 
with  radical  removal  of  the  prostate  if  necessary,  or  with  simple  excision 
of  a  median  bar,  or  isolated  nodule  of  glandular  tissue  if  these  are  found 
to  be  the  cause  of  the  obstruction  to  urination.  It  should  likewise  be 
noted  that  the  Young  punch  operation  was  primarily  intended  for  the 
treatment  of  the  same  type  of  patients. 

Technique. — The  following  description  of  galvano-prostatomy  is 
taken  from  Chetwood's  text-book  of  Urology. 

The  instrument  is  composed  of  a  handle  and  sheath  and  several 
sizes  of  cautery  blades.  The  handle  of  the  instrument  is  graduated  so 
that  the  dimensions  of  the  cut  may  be  determined.  The  sliding  of  the 
knife  is  effected  by  traction  instead  of  the  rotation  of  a  wheel,  so  that 


Chetwood's  Galvano-Prostatomy  247 

the  operator  readily  appreciates  the  progress  of  the  blade  and  the  density 
of  the  tissues  during  cauterization.  One  hand  is  required  to  operate 
the  instrument  and  the  index  finger  of  the  other  hand  is  free  to  be  intro- 
duced into  the  rectum.  No  cooling  device  is  attached  to  the  instrument. 
The  circulation  during  the  operation  of  a  cold  sterilized  solution  through 
the  urethra  and  out  through  the  perineal  wound  is  required  to  keep  the 
handle  of  the  instrument  cool  without  affecting  the  blade.  The  current 
is  supplied  by  a  storage  battery  or  preferably  from  the  street  current 
with  the  aid  of  a  motor  transformer  and  rheostat.  About  50  amperes 
are  required  to  heat  the  knife  to  a  white  heat  which  is  cooled  to  a  certain 
extent  as  it  passes  through  the  tissues. 

The  patient  is  placed  in  the  lithotomy  position,  the  bladder  having 
been  previously  washed  with  boric  acid  solution.  The  preliminary 
step  of  external  perineal  urethrotomy  is  performed.  The  bladder 
having  been  reached,  the  staff  is  removed  and  the  finger  introduced 
through  the  perineal  opening.  In  cases  of  marked  contracture,  whether 
or  not  accompanied  by  hypertrophy,  the  vesical  orifice  may  be  too 
tight  to  admit  the  examining  finger.  This  opening  is  not  forced  and  torn 
by  the  finger,  but  is  enlarged  by  the  first  incision  of  the  cautery  knife. 
The  instrument  having  been  previously  tested,  is  introduced  through 
the  perineal  opening:  the  index  finger  of  the  left  hand  feels  the  beak 
through  the  rectum,  and  irrigation  through  the  urethra  is  commenced. 
The  operator  now  gives  the  signal  to  turn  on  the  current;  ten  seconds 
are  allowed  to  heat  the  knife  after  which  it  is  slowly  unsheathed  by 
drawing  outward.  From  one-half  to  three-quarters  of  a  minute  is 
generally  allowed  to  complete  an  incision  of  moderate  length  (1-2  cm.) 
and  return  the  knife  to  its  sheath.  A  longer  period  is  required  for  an 
incision  of  greater  length.  After  returning  the  knife  to  the  sheath 
irrigation  is  forced  through  the  perineal  incision  before  withdrawing  the 
heated  instrument. 

The  finger  of  the  operator  is  now  introduced  into  the  bladder  and  a 
careful  exploration  made.  In  cases  of  simple  contracture  a  single  in- 
cision of  one  cm.  is  generally  sufficient  to  complete  the  operation.  In 
cases  of  wide,  collar-like  intravesical  hypertrophy,  a  double  incision  may 
be  necessary,  one  on  either  side,  or  a  second  incision  to  deepen  the  first, 
the  aim  being  to  render  the  neck  of  the  bladder  readily  accessible  to 
the  examining  finger. 

Care  should  be  taken  not  to  draw  the  knife  too  far  outward  into  the 
prostatic  urethra  or  so  deep  through  the  contracted  tissue  as  to  completely 
sever  the  internal  sphincter  beyond. 


248  Palliative  Operations 

Following  the  galvano-cautery  incision,  a  perineal  drainage  tube 
is  introduced  and  the  after-treatment  is  the  same  as  after  external  perineal 
urethrotomy,  the  perineal  tube  being  usually  left  in  place  one  or  two 
days  according  to  the  condition  of  the  bladder.  Daily  washing  of 
the  bladder  is  required  through  the  perineal  tube,  and  after  its 
removal,  by  means  of  a  catheter  introduced  through  the  perineal  opening 
and  later  through  the  urethra. 

Cystostomy. — The  establishment  of  a  urinary  fistula  in  the  treat- 
ment of  prostatic  hypertrophy  is  merely  palliative;  it  is  a  remedy  to 
be  employed  only  when  absolute  contra-indications  to  prostatectomy 
exist,  or  in  cases  in  which  prolonged  drainage  of  the  bladder  is  a  neces- 
sary step  in  the  operation  of  prostatectomy. 


Fig.  82. — Result  after  Excision  of  Bar.     {Hugh  H.  Young,  Annals  of 
Surgery.) 

The  aim  of  treatment  differs  under  these  different  circumstances 
and  the  technique  of  the  operation  likewise  differs.  In  performing  a 
cystostomy  which  is  rrierely  preliminary  to  prostatectomy,  our  object 
is  to  provide  free  drainage  of  the  bladder,  but  to  provide  it  in  such 
manner  that  the  prostate  can  be  removed  easily  at  some  future  time 
through  the  fistulous  tract,  enlarged  by  incision  if  necessary,  and  with 
the  assurance  that  the  fistula  will  close  promptly  after  the  removal  of 
the  prostate. 

In  establishing  a  urinary  fistula  for  the  purpose  of  permanent 
drainage  of  the  bladder  our  aim  is,  on  the  contrary,  to  provide  the 
patient  with  a  false  urethra  through  which  the  urine  may  be  evacuated 
at  regular  intervals,  either  voluntarily,  or  by  means  of  the  catheter. 
The  ideal  is  attained  when  the  canal  shows  little  if  any  tendency  to 


Suprapubic   Cystostomy  249 

close  and  at  the  same  time  prevents  the  constant  leakage  of  urine. 

For  the  treatment  of  cases  in  which  prostatectomy  is  inadvisable 
and  in  which  relief  per  urethram  is  impossible,  our  preference  is  for 
suprapubic  cystostomy  with  the  establishment  of  an  artificial  urethra 
by  the  method  of  McGuire.  The  reasons  already  given  for  this  pref- 
erence may  be  reiterated  and  enlarged  upon  in  the  present  chapter. 

In  the  first  place,  the  results  to  the  patient  are  more  satisfactory 
than  when  a  perineal  fistula  is  established.  When  the  artificial  urethra 
remains  as  a  permanent  thing,  the  convenience  and  comfort  of  the 
patient  are  matters  of  considerable  importance.  Incontinence  is 
rarely  a  sequel  of  the  suprapubic  operation;  and  when  it  does  occur, 
is  very  readily  obviated  by  the  use  of  an  obturator  in  the  new  chan- 
nel. Where  the  artificial  urethra  is  in  the  perineum  incontinence  is 
more  likely,  and  when  it  does  exist  no  obturator  will  keep  urine  from 
dribbling  out;  and  the  wearing  of  a  urinal  becomes  necessary,  with  the 
retention  of  a  tube  in  the  perineal  fistula  to  conduct  the  urine  to  its 
receptacle;  since  without  the  tube  the  urine  would  trickle  down  the 
thighs. 

Urination  moreover,  is  usually  more  convenient  through  a  supra- 
pubic than  through  a  perineal  fistula.  In  the  former  case,  if  the  patient 
is  not  able  to  expel  his  urine  in  a  parabolic  stream,  much  as  in  the  normal 
state,  a  soft-rubber  catheter  is  very  readily  dropped  into  the  bladder, 
and  with  a  slight  primary  contraction  the  remainder  of  the  urine  is 
evacuated  by  syphonage.  Patients  with  perineal  fistulse  are  very 
seldom  satisfied  with  their  method  of  urinating;  we  have  heard  them 
compare  it  to  that  of  a  cow. 

lj\By  the  suprapubic  route  the  inflamed  vesical  neck  is  not  injured, 
either  at  the  time  of  operation,  or  in  the  subsequent  treatment  of  the 
patient.  Better  opportunity  is  afforded  for  examination  of  the  interior 
of  the  bladder,  and  for  the  evacuation  of  calculi,  pus,  mucus,  and  blood 
clots. 

The  route  for  drainage  of  the  bladder  and  for  post-operative  irriga- 
tion is  more  direct;  larger  tubes  are  used  for  drainage,  and  as  a  conse- 
quence the  drainage  is  better,  the  tubes  are  less  likely  to  become 
obstructed  or  kinked;  and  convalescence  is  pleasanter  for  the  patient. 

The  prostate  is  usually  so  large  as  to  make  access  to  the  bladder 
from  the  perineum  difficult,  and  to  render  drainage  of  the  post- 
prostatic  pouch  by  this  route  ineffectual.  The  bladder  is  usually 
dilated  and  carried  well  above  the  symphysis,  so  that  it  is  much  more 
readily  reached  by  the  high  operation. 


250 


Palliative  Operations 


But  there  are  certain  cases,  few  in  number  we  acknowledge,  but  still 
worthy  of  consideration,  where  bladder  drainage  is  indicated,  where  it 
cannot  be  obtained  satisfactorily  through  the  urethra,  and  yet  where 
the  bladder  is  small,  thick,  contracted,  and  very  difficult  of  access  by  the 
hypogastric  route.  In  these  patients,  as  a  rule,  the  prostate  is  small 
and  sclerosed,  and  does  not  obstruct  urination  so  much  by  its  size,  as 


Fig.     83. — Suprapubic    Fistula  Established  by  McGuire's  Method,  showing  the 

Obturator. 

by  rendering  the  neck  of  the  bladder  immobile.    In  such  cases  the  advan- 
tages possessed  by  the  perineal  route  are  obvious. 

It  appears  to  us,  then,  that  cystostomy  for  enlargement  of  the 
prostate  is  a  very  valuable  operation,  not  lightly  to  be  discarded.  It 
is  a  step  between  catheterism  and  prostatectomy;  and  while  it  should, 


Suprapubic  Cystostomy  251 

on  the  one  hand,  never  be  undertaken  without  the  hope  of  being  able 
to  cure  the  patient  at  a  later  time  by  the  radical  operation,  yet  it  should 
always  be  doije  in  such  manner  that,  if  further  interference  should 
subsequently  seem  inadvisable,  the  patient  will  nevertheless  recover 
with  an  artificial  urethra  worthy  of  the  name. 

When  employed  only  in  selected  cases  the  operation  of  forming  an 
artificial  urethra  is  attended  by  a  very  slight  mortality.  We  are  not 
aware  that  statistics  of  the  perineal  operation  have  been  published,  but 
the  following  table  gives  the  results  of  McGuire's  operation  (in  cases 
presumably  selected)  in  the  hands  of  various  operators : 

Mortality, 
Operator  Cases  Deaths  Per  Cent. 

Wiesinger 24  o  o .  00 

Bjorn  Hodernus 20  o  o .  00 

Lagoutte 21  4  19.00 

Poncet  and  Delore 39  2  5.12 

McGuire 39  2  5.12 

Horwitz 33  o  o .  00 

Total 176  8  4.54 

Poncet  and  Delore  called  attention  to  the  very  much  greater 
mortality  which  obtains  among  patients  whose  bladders  are  already 
seriously  infected.  Others  they  term  the  mechanical;  but  among  the 
infected  cases  these  authors  record  forty-two  patients  treated  in  this 
manner  by  Lagoutte,  of  whom  fifteen  died,  a  mortality  of  35.7  per 
cent.;  while  of  seventy-five  such  operations  in  their  own  hands,  no  less 
than  twenty-nine  terminated  fatally,  a  mortality  of  38.7  per  cent. 
Watson  published  the  results  of  146  drainage  operations  by  various 
surgeons,  not  classed  as  suprapubic  or  perineal,  but  probably  including 
examples  of  both  operations;  of  these,  forty-nine  terminated  fatally, 
a  mortality  of  33.5  per  cent.  This  high  death-rate  is  probably  to  be 
explained  in  the  same  way  as  that  which  attends  the  infected  cases  of 
Poncet  and  Delore:  because  in  these  cases  the  operation  is  undertaken 
as  a  last  resort,  some  of  the  patients  being  even  moribund  at  the  time, 
and  the  surgeon  adopting  this  form  of  treatment  as  a  forlorn  hope,  or  as 
a  means  of  producing  euthanasia. 

Technique  of  the  Establishment  of  an  Artificial  Urethra  by  Suprapubic 
Cystostomy. — This  operation  may  readily  be  performed  under  local 
anesthesia  with  novocaine,  if  desired;  but  where  the  condition  of 
the  patient  does  not  contraindicate  a  general  anesthetic,  we  prefer  to 
use  ether. 

The  bladder  should  contain  from  90  to  180  cc.  Where  the  urethra  is 
impassable  the  bladder  will  be  distended  by  its  retained  urine. 


252 


Palliative  Operation 


The  surgeon  standing  on  the  patient's  right  side,  an  incision  about 
five  cm.  long  is  made  just  above  the  pubis,  to  one  side  or  the  other 
of  the  linea  alba,  separating  the  fibres  of  the  rectus  muscle  longitudinally. 
This  lateral  position  of  the  incision  decreases  the  chance  of  subsequent 
incontinence,  as  the  muscular  fibres  keep  the  wound  closed  except  when 
separated  by  the  introduction  of  a  tube. 

The  lower  end  of  the  incision  should  touch  the  symphysis  pubis, 
and  at  the  upper  end  the  incision  should  grow  progressively  shorter  as 
it  is  deepened  through  the  abdominal  walls.     No  vessels  or  nerves 


Fig.    84. — I.  Stevenson's    suprapubic  tube.     2.  Senn's  sigmoid  tube  for  a  suprapubic 

fistula. 

large  enough  to  be  named  are  divided,  and  hemorrhage  is  insignificant. 
The  space  of  Retzius  is  now  opened.  The  fat  and  cellular  tissue 
which  fill  it  should  be  carefully  separated  in  the  same  line  as  the 
abdominal  incision,  deviating  neither  to  the  right  nor  left.  Any  large 
veins  should  be  avoided.  If  cut,  however,  they  will  cease  to  bleed  when 
the  bladder  is  opened,  but  can  be  ligated  if  necessary.  It  is  usually 
more  expeditious,  as  well  as  productive  of  less  disturbance  to  the  parts, 
to  dissect  through  this  tissue  with  blunt-pointed  scissors.  Tearing 
it  apart  with  the  handle  of  the  scalpel  or  the  fingers  contuses  it  so  that  it 
is  more  liable  to  infection  from  the  urine. 


Suprapubic   Cystostomy  253 

The  bladder  is  readily  recognized  by  its  bluish  appearance  and  its 
consistency.  The  reflection  of  peritoneum  is  seldom  seen  at  all.  If  in 
the  way,  it  is  readily  separated  from  the  bladder  by  blunt  dissection. 

When  the  bladder  is  reached,  a  silk  or  silkworm-gut  suture  should 
be  passed  through  the  outer  layers  of  its  wall  about  eight  mm. 
on  each  side  of  the  line  of  the  incision.  These  are  to  be  used  as  tractors, 
and  may  be  looped,  or  caught  with  hemostatic  forceps.  They  are  not 
designed  to  remain  after  the  operation,  nor  to  secure  the  bladder  to 
the  abdominal  wall.  Where  the  belly  wall  is  thick,  and  the  introduction 
of  these  sutures  difficult,  a  single  suture  will  suffice ;  this  may  then  be 
placed  in  the  line  of  the  incision,  at  its  upper  limit;  or  a  tenaculum  may 
be  used  to  steady  the  bladder,  as  originally  recommended  by  McGuire. 

The  bladder  being  thus  secured  it  should  be  opened  at  a  point  not 
above  the  upper  margin  of  the  pubis,  the  edge  of  the  knife  being  turned 
downwards.  The  incision  in  its  wall  should  be  longitudinal,  and  amply 
large  to  admit  the  surgeon's  index  finger.  Some  of  these  bladders  have 
very  tough  and  thick  walls,  and  the  opening  does  not  dilate  as  the  finger 
is  introduced.  The  finger  should  follow  the  knife  into  the  bladder 
before  much  of  the  intravesical  fluid  has  escaped,  as  it  will  thus  be  able 
to  gain  a  much  more  accurate  idea  of  the  interior  of  the  bladder. 

Whereas  in  providing  drainage  preliminary  to  prostatectomy  the  open- 
ing into  the  bladder  is  made  as  near  its  summit  as  is  possible,  the 
opening  in  the  bladder  of  a  permanent  fistula  is  placed  close  to  the 
vesical  outlet.  Prompt  closure  of  the  fistula  occurs  after  removal  of 
the  prostate  when  the  opening  is  situated  near  to  the  summit  of  the 
bladder  while  the  permanency  and  efficiency  of  a  fistula  are  in  direct 
proportion  to  the  proximity  of  the  bladder  opening  to  the  vesical  outlet, 
and  to  the  obliquity  of  the  fistulous  tract  in  its  course  through  the 
abdominal  wall. 

Unless  the  prostate  has  been  injured  previously  or  during  the 
operation,  hemorrhage  from  the  interior  of  the  bladder  is  not  apt 
to  be  severe.  It  is  usually  easily  controlled  by  douching  the  bladder 
with  hot  water  or  with  salt  solution.  In  extreme  cases  the  cavity  of  the 
bladder  may  be  packed  with  iodoform  gauze,  which  may  be  pressed 
firmly  against  any  bleeding  point  that  can  be  discovered. 

Any  calculi  present  should  then  be  removed,  and  blood  clots, 
inspissated  mucus,  etc.,  washed  out.  For  such  purposes  it  may 
become  necessary  to  enlarge  the  wound  in  the  wall  of  the  bladder; 
but  it  is  well  to  avoid  this  when  possible. 

A   good-sized  rubber   catheter — about  number  35   to  40  of  the 


254 


Palliative  Operations 


Fig.  85. — Stevenson's    Suprapubic    Tube    in    Place    with    Urinal    Attached. 

(Afler  DaCosta.) 


Suprapubic  Cystostomy  255 

French  scale — or  a  drainage  tube,  should  then  be  inserted  into  the 
bladder,  down  to  but  not  touching  the  post-prostatic  pouch.  A  double 
tube  is  necessary  only  when  vesical  catarrh  is  pronounced.  If  the  tube 
is  carried  down  too  far,  its  end  may  become  hermetically  sealed  by  the 
bladder  contracting  on  it.  It  is  therefore  well  to  have  a  tube  with  a 
lateral  opening,  as  well  as  to  avoid  inserting  it  too  far. 

The  retention  sutures  may  then  be  removed,  and  the  bladder 
in  sinking  back  into  the  pelvis  will  carry  the  vesical  opening  of  the  new 
urethra  even  lower  than  before.  The  tube  may  have  to  be  inserted 
more  deeply  at  this  stage  of  the  operation. 

The  lower  angle  of  the  incision  in  the  anterior  sheath  of  the  rectus 
should  then  be  approximated  with  a  couple  of  interrupted  sutures  of 
chromicized  catgut  or  silk;  and  both  angles  of  the  skin  wound  sutured, 
so  as,  however,  to  allow  the  catheter  to  emerge  higher  than  the  middle 
of  the  original  incision.  In  his  later  operations  McGuire  employed  no 
sutures  at  all,  relying  on  careful  placing  of  the  tube  to  secure  an  artificial 
urethra  of  the  desired  obliquity.  If  the  wound  in  the  bladder  has  been 
enlarged  beyond  that  requisite  to  admit  the  finger,  it  will  of  course 
be  proper  to  apply  a  couple  of  sutures  in  that  position.  This  may 
best  be  done  so  as  to  invert  the  bladder  wall  into  the  cavity  of  this 
viscus,  thus  producing  a  wound  which  is  least  likely  to  result  in  sub- 
sequent incontinence  of  urine. 

The  tube  should  be  sutured  to  the  skin  on  one  side,  to  prevent 
it  slipping  in  or  out.  A  copious  dressing  of  sterile  gauze  and  absorbent 
cotton  is  then  applied;  and  the  tube  connected  by  rubber  tubing  with 
a  urinal  beside  the  bed. 

The  urine  should  be  kept  scrupulously  acid,  both  before  and  after 
the  operation. 

The  patient  may  be  allowed  to  sit  up  in  bed  as  soon  after  the 
operation  as  he  feels  able;  and  may  be  out  of  bed,  as  a  rule,  on  the  fourth 
or  fifth  day. 

If  the  drainage  tube  causes  much  annoyance,  it  may  be  safely 
removed  within  six  or  eight  hours  after  the  operation;  by  which  time 
the  wound  will  have  become  thoroughly  "glazed."  The  tree  dis- 
charge of  urine  through  the  suprapubic  opening  may  be  relied  upon 
to  keep  the  wound  from  closing;  but  it  is  better  to  leave  the  tube  in  the 
bladder  for  at  least  forty-eight  hours  after  the  operation.  If  however, 
it  has  been  removed  earlier  to  relieve  the  patient,  it  can  usually  be 
replaced  after  the  first  day  or  two,  if  necessary  without  producing 
renewed  irritation. 


256 


Palliative  Operations 


Fig.  86. — Senn's  Sigmoid  Catheter  in  Place  with  Tube  Attached  for  Constant 
Drainage  into  Urinal. — (After  DaCosta.) 


Continuous  Drainage  Tubes 


257 


If  the  urethral  obstruction  is  marked  there  is  no  likelihood  of  the 
artificial  urethra  closing;  but  where  this  tendency  is  observed,  a  good- 
sized  tube  should  be  constantly  worn  in  the  wound. 

Where  continuous  drainage,  as  in  cases  of  bad  cystitis,  is  desired, 
one  of  the  many  forms  of  tubes  with  urinals  attached  may  be  employed, 
so  that  the  patient  will  not  be  confined  to  bed.  If  the  vesical  irritability 
is  great,  and  the  prostate  encroaches  much  on  the  cavity  of  the  bladder. 


Fig.  87. — I.  Owen's  perineal  tube.     2.  Watson's  perineal  tube. 


Senn's  sigmoid  drainage  tube  is  probably  the  best  variety.     Stevenson's 
tube  is  another  convenient  form. 

Where  constant  drainage  is  not  required,  but  where  the  bladder 
is  able  to  retain  a  certain  quantity  of  urine  and  needs  only  occasional 
evacuation,  McGuire's  obturator  may  be  worn  in  the  wound;  although 
in  some  cases  no  involuntary  leakage  will  occur  even  without  this 
appliance,  except  when  the  level  of  the  urine  within  the  bladder  becomes 
higher  than  the  external  opening  of  the  artificial  urethra,  or  when  the 
patient  assumes  the  supine  position.  On  removing  the  obturator  the 
patient  may  be  able  to  empty  the  bladder  by  voluntary  contraction; 
but  where  the  vesical  atony  is  extreme  the  introduction  of  a  catheter 
through  the  suprapubic  wound  will  be  necessary. 


17 


258  Palliative  Operation 

REFERENCES  (CHAPTER  XI) 

Bugbee:  Internal.  Abstr.  of  Surg.,  1915,  xxi,  581-593;  Boston   Med.   and  Surg.  Jour., 

1920,  clxxxiii,  41;  80. 
Caulk,  J.  R.:  A  New  Method  of  Removing  the  Median  Bar  Type  of  Prostatic  Obstruction. 

The  Jour,  of  the  Missouri  State  Medical  Assoc,  1921,  xviii,  191. 
Chetwood:  Annals  of  Surgery,  1905,  Ixi,  497;  Surg.,  G}^!.  and  Obst.,  1915,  xxi,  202. 
Gibson:  in  Guit6ras'  Urology,  ii,  p.  306. 
Jacobs,  P.   C:  The  Diagnosis  aiid  Treatment  of  Glandular  Obstruction  at  the  Neck  of 

the  Bladder.     California  State  Jour.  Med.,  1919,  xvii,  56. 
Lower:  Trocar  and  Cannula  for  Suprapubic  Drainage  of  the  Bladder.     Urol,  and  Cut.  Rev. 

1914,  xviii,  6. 
Luys,  G.:  "Fovage  de  la  Prostate"  in  Treatment  of  Prostatic  Hypertrophy.    Jour,  of 

Urol.,  1919,  iii,  17. 
McGuire:  Trans.  Amer.  Surg.  Assoc,  1886,349.;  Ashhurst's  Internat.  Encycl.  of  Surgery, 

1895,  vii,  916. 
Poncet  and  Delore:  Traite  d.  la  Cystostomie  sus-Pubienne  chez  les  Prostatiques,  Paris, 

1899. 
Watson:  Boston  Med.  and  Surg.  Jour.,  1895,  ii,  154. 

Wossidlo:  Centrabl.  f.  d.  Krankheiten  d.  Harn-u-Sexualorg.,  1900,  xi,  113. 
Young:  Jour.  Amer.  Med.  Ass.,  1913,  Ix,  253. 


CHAPTER  XII 

INDICATIONS  FOR  RADICAL  TREATMENT  BY  SUPRAPUBIC 
AND  BY  PERINEAL  PROSTATECTOMY 

The  palliative  treatment  of  prostatics,-  which  formerly  engaged  the 
attention  of  surgeons  in  almost  equal  degree  with  the  radical  forms  of 
treatment,  is  now  reserved  for  cases  who  either  refuse  operation,  or  on 
whom  operation  seems  for  any  reason  unsuited. 

In  this  disease,  as  indeed  in  the  history  of  many  surgical  conditions, 
operative  treatment  has  become  gradually  perfected  to  the  point  where 
radicalism  has  proved  itself  safer   than  any  method  of  palliation. 

In  a  former  edition  of  this  work  the  reader  was  told  that  "when 
palliative  treatment  fails,  then  a  radical  operation  is  indicated."  So 
far  has  surgery  advanced  since  then  that  we  can  now  say,  and,  in  so 
sa)dng  express  a  universal  surgical  opinion,  that  in  the  vast  majority 
of  cases  palliation  should  be  employed  only  as  a  means  of  preparing 
the  patient  for  prostatectomy.  It  is  needless  to  recount  the  develop- 
mental steps  in  operative  technique  which  have  made  prostatectomy  a 
comparatively  safe  procedure;  safe  enough  to  justify  it  as  a  substitute 
for  the  former  necessary  evils  of  catheterism. 

Those  of  us  who  have  Uved  through  this  developmental  period  in 
the  surgery  of  the  prostate  derive  the  keenest  pleasure  in  advising 
operation  in  patients  for  whom  previously  we  would  have  hesitated  at 
the  threshold  of  radicalism,  and  fearing  to  enter  through  its  portals  of 
uncertainty,  would  have  condemned  the  individual  to  a  life  that  is 
brief  on  the  average,  and  certainly  a  miserable  one,  at  least  in  part, 
as  is  the  inexorable  fate  of  these  individuals. 

The  most  recent  development  in  the  surgery  of  the  prostate,  namely 
the  two-stage  operation,  is  believed  by  some  to  meet  the  requirements  of 
a  routine  procedure  but  to  this  we  take  exception  believing  that  this 
method  of  treatment  should  be  selected  only  in  a  certain  class  of  cases. 
For  practical  purposes  of  treatment  we  divide  all  operable  cases  into 
three  groups  as  follows:  Group  I  comprises  all  patients  in  the  initial 
stages  of  prostatism  who  present  no  complications  necessitating  pre- 

259 


26o  Indications  for  Radical  Treatment 

liminary  treatment.  An  individual  belonging  to  this  group  presents 
himself  with  the  history  characteristic  of  a  beginning  adenomatous 
enlargement  of  the  prostate.  His  symptoms  are  mild  in  type;  he  is 
suffering  only  slightly  but  realizes  that  something  is  mechanically  wrong 
with  his  urinary  apparatus.  Patients  of  this  type  usually  belong  to 
the  better  classes,  and  the  more  intelligent  will  most  likely  attribute  the 
nocturia  and  associated  symptoms  from  which  they  suffer  to  a  dis- 
turbance in  the  prostate  gland.  Examination  of  the  prostate  per 
rectum  usually  reveals  a  moderate  degree  of  enlargement  although 
in  many  instances  little  or  no  palpable  change  in  the  organ  can 
be  felt. 

Having  carefully  examined  the  cardiovascular  system  and  ascer- 
tained the  kidney  function;  the  patient  is  given  a  urinary  antiseptic 
for  a  period  of  several  days  at  the  expiration  of  which  time  he  is 
prepared  for  a  cystoscopic  examination  and  the  determination  of  the 
amount  of  residual  urine.  If  we  are  able  to  demonstrate  a  small  quan- 
tity of  residual  urine  in  the  absence  of  marked  distention,  inflammation 
or  atony  of  the  bladder  wall;  if  the  cystoscopic  examination  demonstrates 
sufficient  prostatic  obstruction  at  the  vesical  outlet  to  explain  the 
presence  of  the  residual  urine;  if  the  patient's  vital  organs  are  in  good 
condition;  if  his  kidney  function  is  approximately  normal,  we  deem  it 
not  only  safe  but  wise  to  proceed  at  once  with  the  operation  of 
prostatectomy. 

Unfortunately  this  group  of  cases  is  now  small,  but  the  number  of 
prostatics  who  apply  for  operative  treatment  in  the  incipiency  of  their 
disease  is  increasing.  The  mortality  among  this  group  of  patients 
should  be  almost  nil. 

Group  II,  which  comprises  the  great  majority  of  patients  with  pros- 
tatic hypertrophy,  includes  all  cases  in  which  some  form  of  preparatory 
treatment  is  necessary  if  the  operation  is  to  be  undertaken  with  safety. 
Cases  in  this  group  are  always  moderately  advanced  in  prostatism; 
the  effects  of  urinary  obstruction  are  evident,  primarily  in  the  bladder 
and  the  upper  urinary  tract  and  secondarily,  in  the  general  effects  of 
urinary  stasis  and  in  the  systemic  effects  consequent  upon  a  distress- 
ing affliction. 

There  is  the  history  of  suffering  beginning  as  did  that  of  the  patients 
in  Group  I,  but  gradually  increasing  and  often  made  worse  by  the  instru- 
mental attempts  to  relieve  them.  Almost  all  of  the  patients  are  familiar 
with  catheterism  and  its  effects;  the  majority  of  them  have  infected 
bladders;  a  considerable  degree  of  organic  change  haks  taen  place  in 


Operable   Cases  261 

the  bladder  walls;  and  the  kidney  function  is  diminished  sometimes  to 
a  very  low  ebb. 

The  amount  of  residual  urine  present  varies  but  is  usually  consider- 
able. In  this  group  of  patients  tbe  treatment  has  been  either  that  of 
neglect  or  of  the  palliative  form  including  regular  catheterization,  in 
either  instance  with  results  that  have  prompted  the  patient  to  seek 
operative  relief.  Included  also  in  this  group  are  cases  of  acute  retention 
of  urine  which  is  easily  relieved  by  the  catheter. 

To  attempt  prostatectomy  immediately  in  patients  belonging  to 
this  group  is  to  invite  disaster.  In  the  great  majority  of  instances 
catheterism,  either  intermittent  or  continuous,  together  with  the  treat- 
ment appropriate  to  the  complications  present  will  result  in  an  improve- 
ment sufficient  in  degree  to  permit  of  prostatectomy  being  attempted 
with  every  chance  of  success.  The  operation  may  be  performed  some- 
times in  one  stage;  more  often  it  should  be  done  in  two  stages. 

Some  few  patients  who  at  first  sight  belong  apparently  to  Group  II 
must  be  transferred  to  Group  III  which  includes  those  in  whom  for 
any  reason  palliative  treatment  is  contraindicated  and  in  whom  imme- 
diate rehef  of  urinary  obstruction  is  a  necessity.  This  group  therefore 
includes  all  patients  whose  condition  demands  removal  of  the  prostate 
gland  but  in  whom  instrumentation  is  impossible  and  for  this  reason 
palliative  treatment  cannot  be  carried  out  and  preliminary  cystostomy 
is  therefore  urgently  demanded. 

The  alternative  method  to  cystostomy  under  these  circumstances  is 
tapping  the  bladder  suprapubically,  a  procedure  that  has  a  very  limited 
field  of  usefulness.  It  is  indicated  when  the  circumstances  are  such  that 
an  immediate  suprapubic  cystostomy  cannot  be  done. 

After  determining  the  advisability  of  prostatectomy  in  any  given 
case  we  must  next  carry  out  the  preliminary  treatment  designed  to 
get  the  patient  in  the  best  possible  condition  for  operation.  Having 
succeeded  in  this,  we  choose  the  method  of  operation  best  suited  to  the 
needs  of  the  individual  case.  We  have  before  us  a  choice  of  two  routes 
of  access  to  the  prostate  gland,  the  suprapubic  and  the  perineal;  and  a 
number  of  variations  in  the  operative  procedure  by  either  route.  To 
determine  which  of  these  many  different  methods  is  applicable  to  any 
given  case,  is  the  task  at  present  before  us.  The  technique  of  the 
operations  will  be  described  in  the  next  chapter. 

Those  surgeons  who  would  confine  their  operative  technique  to  either 
the  suprapubic  or  the  perineal  route  alone,  and  who  do  not  admit  that 
in  some  cases  one  route  may  justly  be  preferred  to  the  other,  so  that  each 


262  Indications  for  Radical  Treatment 

is  occasionally  employed,  appear  to  us  to  be  very  narrow-minded,  and 
to  be  looking  at  the  subject  with  prejudiced  eyes.  There  is  no  more 
reason  for  one  method  of  operating  on  the  prostate  being  exclusively 
applicable  to  every  case,  than  there  is  for  one  incision  or  one  avenue 
of  approach  being  always  the  only  one  possible  in  other  condi- 
tions. For  cleaning  out  the  sphenoid  cells,  for  example,  it  will  some- 
times be  better  to  approach  them  from  above,  through  the  frontal 
sinuses,  while  at  other  times  entrance  will  be  more  safely  gained  through 
the  middle  meatus  of  the  nose.  For  draining  the  lesser  peritoneal 
cavity  it  will  at  times  be  more  advantageous  to  open  through  the  left 
loin,  while  at  other  times  the  transabdominal  route  will  be  proper.  For 
the  operation  of  hysterectomy  an  abdominal  operation  will  usually  be 
preferred;  but  there  are  times  when  a  vaginal  excision  will  give  better 
results.  So  with  the  operation  of  prostatectomy — the  suprapubic 
operation  is  in  certain  cases  (we  think  in  the  majority)  in  every  way  pref- 
erable to  that  through  the  perineum.  No  doubt  a  skillful  surgeon 
will  in  time  become  able  technically  to  remove  all,  or  nearly  all,  enlarged 
prostates  by  one  or  the  other  route  exclusively;  but  this  does  not  prove 
that  in  a  certain  few  cases  a  resort  to  the  neglected  route  would  not 
result  in  an  easier  operation,  and  recovery  be  more  assured,  as  well.  Mr. 
Freyer,  who  is  inclined  to  the  opinion  that  all  enlarged  prostates  are 
best  removed  by  means  of  the  suprapubic  operation  which  bears  his 
name,  nevertheless  met  with  one  case  (Brit.  Med.  Journ.,  1902,  ii,  248; 
ibid.,  1903,  i,  901)  in  which  he  was  unable  to  remove  the  prostate  by 
this  route;  and  the  patient  died  of  heart  failure,  a  couple  of  days  after 
the  unsuccessful  operation,  the  bladder  at  autopsy  being  found  to  be 
full  of  clots.  Now,  this  result  is  very  far  from  proving  that  the  prostate 
in  this  individual  patient  could  have  been  satisfactorily  removed  by 
a  perineal  operation,  but  it  certainly  shows  that  no  one  method  can  be 
exclusively  employed,  if  we  aim  to  secure  the  best  results.  And  since 
Mr.  Freyer  may  be  supposed  to  possess  more  skill  in  the  performance 
of  his  operation,  as  he  certainly  has  had  more  experience  than  any  one 
else,  it  is  but  reasonable  to  conclude  that  where  he  has  failed,  others 
will  fail  as  well.  We  once  saw  a  distinguished  surgeon  in  a  neighboring 
city  operate  by  perineal  prostatectomy,  and  although  he  finally  did 
succeed  in  extracting  the  diseased  organ,  yet  he  sweat  blood  throughout 
the  operation,  and  there  was  for  some  time  grave  anxiety  as  to  the  life 
of  the  patient.  This  surgeon  was  one  of  those  who  advocate  the 
perineal  operation  for  every  case;  and,  as  in  the  parallel  case  of  Mr. 
Freyer.  it  may  reasonably  be  supposed  that  those  surgeons  who  employ 


Choice  of  Operation  263 

one  operation  exclusively  will  be  more  apt  to  make  it  succeed  in  diffi- 
cult cases  than  will  those  who  have  no  objection  to  resorting  to  a 
different  method  when  they  think  the  one  they  usually  prefer  will  fail. 
There  may  be,  indeed  we  have  little  doubt  that  there  are,  prostates 
which  can  be  removed  neither  by  one  route  nor  the  other;  but  there  can, 
we  think,  be  no  question  that  the  surgeon  will  do  best  for  his  patients, 
as  well  as  for  his  own  reputation,  who  is  competent  to  resort  to  either 
method  of  treatment,  as  may  seem  indicated  to  him. 

Speaking  in  favor  of  suprapubic  prostatectomy,  and  referring  to 
Watson's  statement  that  the  perineal  distance  is  so  great  in  one- third  of 
the  cases  as  to  prevent  the  completion  of  the  operation  by  the  perineal 
route,  McGUl  said  "it  is  unwise  to  commence  an  operation  with  the 
probability  of  faihng  in  one-third  of  the  cases;"  and  "it  is  not  advisable 
to  limit  the  ability  to  perform  an  operation  to  gentlemen  with  preterna- 
turally  long  fingers;"  while  Moore  asserts  that  the  operator's  fingers 
grow  longer  as  he  grows  in  experience  in  the  perineal  operation.  Both 
these  statements,  while  epigrammatic,  are  no  doubt  true;  but  they  do 
not  invaUdate  the  principle,  already  laid  down,  that  the  ability  to 
operate  by  both  routes  is  a  prerequisite  for  the  most  successful 
treatment. 

This  being  accepted  as  an  axiom,  it  will  be  the  surgeon's  next  duty 
to  determine  which  cases  are  suited  to  each  method  of  operation.  It  will 
be  recollected  that  enlargement  of  the  prostate  occurs  in  two  main  varie- 
ties— one  variety,  the  glandular  or  adenomatous  overgrowth,  constitut- 
ing the  majority  of  cases;  while  the  fibrous  enlargement  constitutes 
the  minority,  and  even  at  times  approaches  more  nearly  in  type  to 
prostatic  atrophy,  or  to  sclerosis  of  the  neck  of  the  bladder,  or  is  at  least 
conspicious  by  the  relatively  sHght  enlargement  compared  to  the 
magnitude  of  the  symptoms  produced.  In  the  former  variety,  as  has 
already  been  pointed  out,  the  prostate  attains  a  greater  size,  and  at  the 
same  time  the  bladder  is  more  often  dilated  than  contracted.  In 
the  latter  variety,  which  seems  rather  intimately  connected  with 
inflammatory  changes,  the  bladder  is  usually  small  and  thickened. 
Hence  at  the  onset  we  have  the  general  law  laid  down  that  the  hard, 
small  fibrous  prostate  will  usually  be  very  difl&cult  of  access  by  the 
suprapubic  route,  while  the  adenomatous  organ  will  at  times  be  so 
bulky  as  to  absolutely  prevent  its  removal  through  the  perineum,  except 
by  fragmentation.  It  was  in  a  case  .of  the  former  variety  that  Mr. 
Freyer  found  himself  unable  to  complete  his  suprapubic  operation,  for 
although  the  gland  could  be  satisfactorily  reached,  yet  it  could  not  be 


264  Indications  for  Radical  Treatment 

removed  because  of  its  intimate  adherence  to  the  surrounding  structures. 
As  has  been  frequently  insisted  upon  by  Mr.  Freyer,  the  adenomatous 
glands  gradually  "shake  themselves  loose"  from  the  surrounding  struc- 
tures, tend  to  resume  their  bi-lobed  condition,  and  are  easily  enucleated 
by  the  finger.  But  where  the  organ  is  fibrous,  and  where  periprostatitis 
(which  usually  has  accompanied  the  development  of  this  variety)  has 
existed,  the  adhesions  between  the  prostatic  capsule  and  its  sheath  are 
very  dense,  no  natural  line  of  cleavage  exists,  and  enucelation  is  there- 
fore difficult  or  impossible.  Where  prostates  which  approach  the  fibrous 
type  (for  a  number  are  intermediate  in  character)  are  removed  by 
enucleation,  portions  of  the  sheath,  or  even  of  the  levator  ani  muscle, 
are  frequently  found  adhering  to  the  outer  surface  of  the  organ,  it 
having  been  impossible  to  separate  the  capsule  from  the  sheath  on  all 
sides.  Yet  i^i  the  fibrous  prostates  no  subsequent  increase  in  size  is 
to  be  apprehended,  and  the  removal  of  the  floor  of  the  urethra,  together 
with  as  much  of  the  lateral  lobes  as  may  be  requisite,  will  result  in 
sufficient  lowering  of  the  vesical  outlet  to  accomplish  the  desired  result; 
whereas  a  similar  operation — a  partial  prostatectomy — in  the  case  of 
an  adenomatous  prostate  still  increasing  in  size,  would  indeed  give 
temporary  relief,  but  might,  on  the  other  hand,  be  followed  by  continued 
growth  in  the  remaining  portions  of  the  prostate,  which  would  eventually 
cause  renewed  urinary  obstruction.  For  such  cases,  therefore,  complete 
enucleation  is  preferable,  and  that  this  may  be  more  readily  and  satis- 
factorily accomplished  by  the  suprapubic  route  we  will  presently 
endeavor  •  to  show. 

But  it  is  proper  at  this  place  to  sound  a  note  of  conservatism. 
Many  surgeons  are  roUing  up  long  lists  of  successful  (or  unsuccessful) 
operations  by  either  the  suprapubic  or  the  perineal  route.  But 
it  appears  to  us  that  some  such  operators  may  be  a  little  hasty  in  resort- 
ing to  operative  interference;  and  while  one  death  from  neglect  to  oper- 
ate at  the  proper  time  is  more  reproach  to  a  surgeon  than  several  deaths 
which  a  timely  operation  merely  failed  to  prevent,  even  though  the 
former  death  never  appears  in  his  statistics;  yet  one  death  clearly  caused 
or  hastened  by  an  ill-judged  resort  to  operative  treatment  will  demand 
an  immense  number  of  successes  to  blot  out  its  remembrance.  And  we 
cannot  but  think  that  some  surgeons  are  displaying  more  enthusiasm  in 
adding  many  operations  every  year  to  their  tale  of  cases,  than  they  are 
in  seeking  the  best  interests  of  their  patients. 

And  in  connection  with  these  thoughts,  we  would  like  to  insist  upon 
the  propriety  of  not  doing  too  much  at  any  one  operation.     If  we  open 


Choice  of  Operation  265 

the  bladder  to  drain  it  for  cystitis,  let  us  be  satisfied,  except  in  rare 
instances,  if  we  secure  the  desired  drainage,  and  let  us  not  attempt  to 
remove  the  prostate  at  the  same  time.  If  we  open  the  bladder  prepared 
to  do  a  prostatectomy,  and  find  a  pedunculated  outgrowth  acting  as  a 
ball-valve  against  the  vesical  orifice  of  the  urethra,  let  us  be  satisfied 
to  remove  it,  and  leave  the  remainder  of  the  prostateal  one.  We  do  not 
think  we  can  justly  be  accused  of  timidity,  but  we  are  free  to  confess 
that  we  are  afraid  to  do  too  much  to  some  of  these  decrepit  old  men : 
their  tenure  on  life  is  slight,  and  pressing  our  manipulations  too  far 
may  at  any  moment  loose  the  silver  cord,  and  instead  of  curing  the 
patient  by  a  brilUant  operation,  we  shall  have  killed  him  by  meddlesome, 
injudicious  surgery. 

We  know  quite  well  that  in  a  certain  number  of  cases  removal  of  a 
pedunculated  outgrowth  has  not  prevented  a  return  of  symptoms;  but, 
on  the  other  hand,  we  are  perfectly  familiar  with  several  instances  where 
the  most  radical,  dangerous,  brilliaat,  and  remarkable  operation  in  the 
world  could  have  had  no  more  successful  result  than  the  simple  snipping 
off  of  such  a  ball- valve,  with  scarcely  more  present  danger  to  the  patient 
than  that  of  the  anesthetic.  And  although  Mr.  Freyer  has  made 
somewhat  caustic  remark's  upon  the  futility  of  employing  anything 
else  than  total  enucleation  in  any  such  cases,  we  have  had  too  many  cases 
of  this  kind  with  satisfactory  results  following  this  simple  procedure  to 
allow  ourselves  to  be  influenced  even  b)'^  Mr.  Freyer  for  whose  judgment 
and  experience  we  have  nevertheless  the  deepest  respect. 

The  following  case  history  well  illustrates  a  cure  by  this  procedure. 

J.  S.,  aged  sixty-nine  years,  had  been  forced  for  seven  or  eight 
years  to  rise  during  the  night  to  urinate.  The  desire  was  imperative, 
and  sometimes  recurred  ten  or  twelve  times  during  the  same  night. 
There  was  difficulty  in  starting  the  stream,  and  only  a  small  quantity 
was  passed  at  any  one  time.  Vesical  tenesmus  occurred  at  frequent 
intervals,  both  day  and  night.  On  admission  to  the  Lankenau 
Hospital,  the  patient  was  found  to  be  plethoric;  his  color  was  sallow; 
his  arteries  were  somewhat  atheromatous,  and  their  tension  increased. 
His  heart-sounds  were  muffled,  and  the  second  cardiac  sound  was 
accentuated  throughout.  His  lungs  were  emphysematous.  There 
was  tenderness  in  the  pubic  region,  and  combined  intravesical  and 
rectal  examination  demonstrated  an  enlarged  "median  lobe"  of  the 
prostate.  There  were  60  cc.  of  residual  urine.  The  pedunculated 
"median  lobe"  was  removed  by  suprapubic  cystostomy,  by  means  of 
large  forceps.     Bleeding  was  free,  but   easily   controlled.     A  rubber 


266  Indications  for  Radical  Treatment 

tube  was  inserted  through  the  suprapubic  wound,  which  was  not 
sutured.  The  patient  was  discharged,  well,  in  two  weeks.  We  have 
heard  from  him  frequently  since,  and  on  recent  inquiry,  four  years  after 
operation,  ascertained  that  his  urination  was  normal  in  every  respect. 

Other  similar  cases  are  to  be  found  in  prostatic  literature,  but  they 
seem  to  have  passed  from  the  memory  of  many  in  the  profession. 
Burckhardt  recorded  the  case  of  a  patient  who  had  suffered  from 
urinary  symptoms  for  five  and  a  half  years;  and  who  for  one  year  had 
had  frequent  attacks  of  retention  of  urine.  By  removal  of  a  projecting 
"middle  lobe"  by  suprapubic  cystostomy,  all  the  symptoms  were  re- 
lieved ;  and  when  last  seen,  four  and  a  half  years  after  the  operation,  the 
patient  was  in  good  health,  and  his  urinary  functions  were  normally 
performed.  Prof.  Ashhurst  reported  a  case  of  similar  nature,  as  long 
ago  as  1882.  The  patient  for  five  years  had  been  absolutely  dependent 
on  the  catheter.  Finally  the  end  of  his  catheter  broke  off  and  remained 
in  the  bladder.  After  suffering  for  seven  weeks  from  this  added  dis- 
comfort, he  applied  for  treatment.  The  foreign  body  was  removed  by 
median  perineal  cystostomy,  and  a  pedunculated  "median  lobe"  of  the 
prostate  was  removed  at  the  same  time.  On  recovery  the  patient 
found  to  his  great  delight  that  he  could  pass  his  urine  in  the  normal 
manner,  and  had  no  further  use  for  the  catheter.  Harrison  reported 
another  such  recovery. 

To  these  few  instances  others  might  be  added,  but  those  given  are 
sufficient  to  emphasize  our  point. 

The  preferable  route  for  total  enucleation  of  the  prostate  is  the 
suprapubic.  The  prostate  lies  upon  the  triangular  ligament,  and  above 
the  aponeurosis  of  DenonvilHers;  neither  of  these  structures,  so  impor- 
tant in  completing  the  floor  of  the  pelvis,  is  divided  when  the  prostate 
is  lifted  off  them,  and  delivered  into  the  cavity  of  the  bladder.  And 
when  the  prostate  is  adenomatous  in  character  its  enucleation  is  accom- 
plished with  surprising  ease.  Whether  the  prostatic  urethra  is  removed 
or  not,  apparently  makes  no  difference  in  the  functional  result.  In 
many  of  the  older  perineal  operations  it  is  sacrificed  in  a  similar 
manner.  Indeed,  Goodfellow's  procedure  appeared  to  be  precisely  the 
same  as  Mr.  Freyer's,  except  that  the  former  removed  the  prostate 
through  a  perineal  incision. 

The  approach  to  the  prostate  by  the  suprapubic  route  is  through 
structures  which  are  less  vascular,  and  less  liable  to  permanent  injury 
from  the  necessary  manipulations.  They  are,  moreover,  not  required 
for  the  function  of  urination.     It  is  customary  to  cast  in  the  teeth  of  the 


Choice  of  Operation  267 

suprapubic  operator  the  fact  that  he  makes  two  incisions  in  the  bladder 
wall,  one  on  its  superior  surface,  to  enter  its  cavity,  and  another  in  its 
floor  to  reach  the  prostate;  and  it  is  pointed  out  by  perineal  operators  that 
the  organ  whose  removal  we  are  attempting  lies  entirely  outside  the 
bladder,  and  that  by  the  perineal  approach  the  bladder  wall  is  not  divided. 
But  those  surgeons  who,  like  Goodfellow,  insisted  upon  the  propriety  of 
entering  the  enucleating  finger  into  the  bladder  cavity  before  beginning 
the  enucleation,  surely  divided  the  floor  of  this  viscus  during  their 
maneuvers;  while  those  who,  like  Proust  and  Young,  approach  the 
prostate  from  its  lower  side,  employ  an  extensive  dissection  separating 
the  rectum  from  the  anterior  structures,  and  dividing  the  base,  or 
working  around  the  lower  margin  of  the  triangular  ligament,  and  thus 
in  either  case  form  a  wound  which,  as  their  results  show,  is  more  apt  to 
result  in  a  permanent  fistula,  while  it  affords  no  better  drainage 
than  is  procured  by  the  suprapubic  operation.  As  was  pointed  out  by 
McGill  and  W.  G.  Richardson,  drainage  is  really  better  by  the  supra- 
pubic wound;  for  it  is  a  tact  that  where  the  bladder  is  drained  both  ways 
simultaneously  almost  all  the  urine  escapes  by  the  suprapubic  tube,  and 
that  when  both  tubes  are  removed,  the  perineal  tract  closes  first.  This 
is,  of  course,  where  the  perineal  wound  is  a  simple  median  urethrotomy, 
since,  as  has  already  been  said,  the  wound  left  after  a  suprapubic 
cystostomy  closes  more  rapidly  than  that  resulting  from  the  extensive 
perineal  operations. 

As  to  the  objection  that  the  prostate  is  an  extravesical  organ, 
it  may  be  repUed  that  it  is  so  to  the  same  extent  as,  but  scarcely  more  so 
than  the  appendix  is  an  extraperitoneal  structure;  for  the  enlarged 
prostate  (and  it  is  only  that  form  that  we  are  discussing  now)  almost 
invariably  becomes  chiefly  intravesical  in  character,  and  it  is  therefore 
no  more  unsurgical  to  traverse  the  bladder  to  reach  it  than  it  is  to  attack 
the  appendix  by  a  transperitoneal  route;  and  yet  we  all  know  that  an 
inflamed  appendix  may  readily,  if  circumstances  require  it,  be  stripped 
out  from  its  peritoneal  covering,  leaving  this  in  place  like  the  empty 
finger  of  a  glove,  much  as  the  perineal  operators  advocate  scoop- 
ing out  submucous  prostatic  outgrowths  from  beneath  the  floor  of  the 
bladder  without  opening  this  organ;  but  nevertheless  no  one  will  prefer 
an  extraperitoneal  approach  to  the  appendix.  The  enlarged  prostate, 
in  fact,  is  covered  only  by  mucous  membrane,  or  at  most  by  attenuated 
muscular  tissue  which  is  as  much  prostatic  capsule  as  it  is  bladder  wall. 

The  mortaUty  of  Freyer's  operation  is  higher  than  that  shown 
by  the  statistics  of  the  modern  perineal  operations;  but  of  the  cases  that 


268  Indications  for  Radical  Treatment 

recover,  those  that  are  classed  as  good  results  form  a  somewhat  larger, 
and  those  with  perfect  cures  a  considerably  larger  proportion. 

These  facts  which  were  originally  established  by  statistics  collected 
during  the  earlier  years  of  the  radical  operation  of  prostatectomy  have 
been  confirmed  many  times  by  subsequent  writers. 

The  statistics  which  we  have  collected  from  the  more  recent  litera- 
ture and  from  personal  communications  with  confreres  as  well  as 
our  own  experience  confirms  the  validity  of  the  statement  that  the 
primary  mortality  is  slightly  greater  following  the  suprapubic  opera- 
tion than  it  is  after  perineal  prostatectomy,  but  this  disad- 
vantage is  more  than  offset  by  the  far  better  results  obtained  in  cases 
which  recover  after  the  suprapubic  operation  than  after  perineal 
prostatectomy.  • 

This  subject  is  discussed  at  some  length  in  the  chapter  on  prognosis 
to  which  the  reader  is  referred. 

We  at  one  time  also  advocated  the  perineal  as  the  preferable  opera- 
tion, because  of  the  difficulties  and  dangers  attendent  upon  McGill's 
suprapubic  method;  but  when  after  seeing  Mr.  Freyer's  excellent  results, 
and  appreciating  the  force  of  his  arguments,  we  were  emboldened  to 
attempt  a  similar  operation,  and  were  greatly  surprised  at  the  simpli- 
city of  the  technique,  and  at  the  pleasant  convalescence  of  the  patient. 
This  ease  of  performance  is  another  argument  in  favor  of  the  supra- 
pubic route.  For  although  mere  facility  of  execution  by  the  surgeon 
is  of  itself  no  valid  argument  in  favor  of  one  operation  rather  than 
another,  provided  this  other  would  secure  better  results  and  entail  less 
danger  to  the  patient,  yet  in  Freyer's  operation  the  ease  consists  not 
alone  in  mechanical  execution,  but  in  rapidity  of  performance,  less 
distortion  of  neighboring  parts,  and  less  likelihood  of  post-operative 
complications;  all  of  which  are  factors  of  much  importance  in  old 
prostatics. 

The  perineal  operation,  as  we  have  already  stated,  we  think,  is  best 
confined  to  those  cases  where  the  prostate  is  small,  fibrous,  and  scler- 
osed; where  the  removal  of  the  floor  of  the  prostatic  urethra  and  the 
main  part  of  the  lateral  lobes  of  the  prostate  will  lower  the  vesical 
orifice  sufficiently  to  make  a  clear  water-way;  and  where  there  is 
Httle  chance  of  the  only  portion  of  the  prostate  left  (the  superior 
commissure)  subsequently  enlarging  and  causing  renewed  obstruction. 
Where  the  prostate  is  of  the  character  described  it  is  usually  impossible, 
or  at  all  events  extremely  difficult,  to  enucleate  it  from  within  its  sheath; 
and  a  more  or  less  exact  dissection  is  required.     To  accomplish  this 


Suprapubic  Prostatectomy  269 

through  a  suprapubic  wound  is  nearly  impossible,  since  the  prostate  is 
at  such  a  distance  from  the  surface;  but  when  it  is  well  drawn  down 
into  the  perineum  by  tractors  of  some  variety,  such  a  dissection  may 
usually  be  accomplished. 

As  to  the  preservation  of  the  ejaculatory  ducts,  we  regard  this  as 
entirely  unnecessary.  As  shown  in  a  former  chapter,  it  is  extremely 
improbable  that  semen  without  the  admixture  of  prostatic  fluid  is 
fertile;  and  the  destruction  of  these  ducts  need  not  of  itself  cause  impo- 
tence. Impotence  often  exists  before  the  operation;  and  although  it 
has  been  stated  that  removal  of  the  prostate  may  restore  sexual  potency, 
yet  of  this  we  are  not  very  sanguine. 

It  will  be  seen  from  the  preceding  paragraphs  that  we  prefer  supra- 
pubic prostatectomy  as  the  radical  treatment  for  the  majority  of 
patients.  Indeed,  since  first  adopting  this  method  we  have  seen  few 
cases  in  which  it  did  not  seem  preferable  to  the  perineal  operation;  but 
we  recognize  the  fact  that  there  are  cases  where  the  perineal  is  to  be 
preferred,  and  when  we  encounter  such,  we  do  not  hesitate  to  adopt  the 
latter  procedure. 

We  do  not  employ  the  various  endo-urethral  forms  of  opera- 
tive treatment  for  the  removal  of  median  bars  or  the  relief  of 
contractures  of  the  vesical  neck  and  kindred  conditions.  It  has 
always  seemed  to  us  to  be  the  part  of  better  judgment  to  open  the 
bladder  suprapubically  in  this  class  of  patients  and  remove  the  obstruc- 
tion under  the  guidance  of  the  eye,  preferably  with  the  aid  of  the  rongeur 
forceps,  sometimes  with  the  knife  by  a  procedure  similar  to  that 
recently  described  by  Buerger,  and  rarely  with  the  cautery.  Occa- 
sionally a  case  is  met  with  in  which  the  prostate  has  been  removed  by 
the  suprapubic  route  but  in  which  a  tab  of  mucosa  attached  to  the 
margin  of  the  prostatic  bed  is  so  situated  as  to  obstruct  the  urethra 
and  interfere  with  the  emptying  of  the  bladder.  After  accurate  cysto- 
scopic  localization  of  an  obstructive  factor  of  this  type  it  may  in  certain 
instances  be  removed  with  ease  with  the  Young  punch.  Usually  how- 
ever we  prefer  to  re-open  the  bladder  in  these  cases,  which  are  fortunately 
rare.  Indeed,  additional  operative  procedures  are  rarely  necessary 
to  complete  the  cure  after  a  total  suprapubic  prostatectomy. 

REFERENCES  (CHAPTER  XII) 

Ashhurst:  Principles  and  Practice  of  Surgery,  Phila.,  1893,  6th  ed.,  p.  1026. 
Buerger:  Jour.  Amer.  Med.  Ass.,  1919,  Ixxiii,  1677. 
Goodfellow:^Jour.  Amer.  Med.  Ass.,  1904,  ii,  194. 


270  Palliative  Operation 

Harrison:  British  Med.  Jour.,  1902,  ii,  1499. 

McGill:  Trans.  Clin.  Soc,  London,  1888,  xxi,  52. 

Moore:  Trans.  Amer.  Surg.  Ass.,  1902,  xx,  59. 

Proust:  Manuel  de  la  Prostatectomie  Perin^ale  pour  Hypertrophic,  Paris,  1903. 

Richardson:  Development  and  Anatomy  of  the  Prostate  Gland,  London,  1904. 

Socin  and  Burckhardt:  Die  Verletzungen  und  Krankheiten  der  Prostata,  Stuttgart,  1902. 

Watson:  Annals  of  Surgery,  1889,  ix,  i. 

Young:  Jour.  Amer.  Med.  Ass.,  1903,  ii,  999. 


CHAPTER  XIII 

TECHNIQUE  OF  OPERATIONS,  INCLUDING  THE  PREPARA- 
TION OF  THE  PATIENT,  WITH  THE  AFTER-TREATMENT 

Preparation  of  the  Patient. — The  preparation  of  the  patient  is 
essentially  the  same  no  matter  by  which  route — suprapubic  or 
perineal — the  prostate  is  to  be  removed. 

These  are  not  emergency  operations,  and  the  patient  should  be 
under  preparation  for  the  operation  for  a  time  sufl&cient  to  restore 
the  vital  organs  to  their  maximum  functional  power.  In  the  case  of 
many  patients  the  surgeon  will  have  been  in  attendance  for  weeks  or 
months;  but  even  such  patients  require  further  preparation  than  mere 
surgical  attention.  This  preparation  should  be  both  general  and  local 
As  to  constitutional  treatment,  it  is  well  to  pay  special  attention  to  the 
condition  of  the  kidneys,  the  heart,  and  the  lungs. 

As  regards  the  details  of  pre-operative  treatment — both  local  and 
general — these  have  been  described  in  the  discussion  of  renal  functional 
tests  and  the  palliative  treatment  of  prostatic  obstruction.  We  wish 
merely  to  recall  to  the  reader's  mind  the  urgent  necessity  for  pre-opera- 
tive treatment  in  all  cases  of  prostatic  hypertrophy.  Treatment  of 
the  kidneys  is  governed  by  the  state  of  renal  function  which  is  almost 
invariably  impaired  when  the  patients  come  under  observation  for  the 
first  time.  Such  treatment  must  differ  necessarily  in  different  cases 
since  no  two  individuals  present  exactly  the  same  alterations  in  kidney 
function.  In  one  group  of  cases,  a  simple  dietary  and  hygienic  regimen 
is  the  only  pre-operative  treatment  necessary;  at  the  other  extreme  is  a 
group  in  which  impending  uremia  necessitates  prolonged  treatment 
which  may  or  may  not  include  preliminary  cystostomy. 

Selection  of  the  time  for  prostatectomy  even  in  cases  in  which 
preliminary  cystostomy  has  been  done  is  quite  as  perplexing  a  problem 
as  the  selection  of  the  proper  form  of  pre-operative  treatment.  Indeed, 
in  no  other  surgical  condition  is  the  necessity  for  wide  surgical  exper- 
ience and  fine  judgment  greater;  the  most  consummate  technical  skill 
is  powerless  to  offset  the  evils  of  ill-advised  surgery,  and  the  patient 
whose  time  for"  operation  has  been  chosen  scientifically  has  a  better 
chance  for  recovery  in  the  hands  of  a  veritable  tyro  in  surgery  than  the 

271 


272  Technique  of  Operations 

patient  who  is  operated  upon  by  a  master  technician  before  the  kidney 
function  has  been  restored. 

For  the  heart  it  is  usually  well  to  prescribe  a  course  of  strychnine 
or  digitalis,  even  if  the  cardiac  action  is  not  noticeably  abnormal.  The 
shock  of  the  operation  is  a  strain  even  on  a  well-preserved  heart;  but 
it  may  be  much  lessened  by  getting  the  heart  into  training 
previous  to  the  operation.  In  our  hospital  experience  we  have 
found  that  resident  physicians  are  only  too  apt  to  overdose  the 
patient  with  strychnine  after  the  operation,  while  omitting  it  in  the 
preparation. 

The  lungs  should  of  course  be  free  from  acute  disease,  such  as 
bronchitis;  and  where  a  more  or  less  chronic  or  subacute  bronchitis, 
hypostatic  congestion,  asthma,  or  emphysema  is  present,  special  care 
should  be  exercised  in  the  administration  of  the  anesthetic,  as  well  as 
in  the  prevention  of  chilling  or  exposure.  For  such  patients  we  prefer 
nitrous-oxide  oxygen  to  ether.  Drugs  directed  to  the  condition  of  the 
lungs  are  usually  of  little  use,  but  if  the  heart  is  treated  the  lungs  may  be 
benefitted  indirectly. 

It  is  not  usually  advisable  to  confine  the  patient  to  bed  even  on  the 
day  immediately  preceding  the  operation,  unless  he  is  already  bed- 
ridden: it  is  sufficient  for  him  to  regulate  his  life  with  the  utmost  care, 
confining  himself  to  the  house,  and  taking  special  precaution  to  break 
no  well-established  habits  of  Hfe.  On  the  morning  of  the  operation  he 
should,  of  course,  remain  in  bed.  It  is  well  to  have  the  services  of  a 
trained  nurse  for  at  least  twenty-four  hours  before  the  operation. 

The  alimentary  canal  should  be  well  cleaned  out  by  a  brisk  cathartic 
given  in  the  afternoon  before  the  operation,  and  the  rectum  should  be 
emptied  by  enema  on  the  morning  of  the  operation.  Should  the 
afternoon  cathartic  not  act,  it  is  to  be  repeated  early  in  the  evening  or  on 
the  following  morning,  before  the  operation.  If,  as  has  been  advised, 
the  patient  has  been  in  the  habit  of  taking  a  cathartic  about  once  in  a 
week  or  ten  days,  no  difficulty  will  be  experienced  in  thoroughly 
emptying  the  intestinal  tract  without  the  use  of  drastic  purges.  In- 
deed, the  routine  administration  of  cathartics  to  patients  as  practised 
in  some  hospitals  in  preparation  for  operation  is  debilitating  in  the  ex- 
treme; the  patient  being  in  no  fit  condition  to  undergo  a  serious  opera- 
tion after  a  sleepless  and  frequently  disturbed  night.  We  think  that  one 
good  free  movement,  which  may,  as  a  rule,  be  procured  by  one  dose 
(15  cc.)  of  epsom  salts  or  of  castor  oil,  together  with  an  enema 
on  the  morning  of  operation,  will  evacuate  the  intestinal  tract  quite 


Preparing  the  Patient  273 

sufficiently;  and  we  can  see  no  sense  in  repeatedly  purging  patients  until 
exhaustion  is  produced. 

The  diet  for  the  few  days  preceding  the  operation  should  be  light; 
and  the  supper  the  evening  before  may  best  be  confined  to  fluids 
(milk,  broth,  gruel,  milk- toast,  etc.),  and  perhaps  a  soft-boiled  or 
poached  egg,  with  a  little  stale  bread.  If  the  laxative  is  taken  before 
supper,  such  a  meal  will  leave  comparatively  little  residue,  and  this  may 
be  removed  by  an  enema  in  the  morning.  Plenty  of  fluid  may  be 
taken  up  to  within  about  six  hours  of  the  operation.  This  will  flush 
out  the  kidneys,  and  help  to  refill  the  vascular  system,  which  is  always 
somewhat  depleted  if  a  saline  purge  is  employed.  If  the  operation  is 
not  to  take  place  until  afternoon,  a  light  breakfast  (broth  or  gruel) 
should  be  allowed,  but  this  should  be  omitted  when  the  operation  is  to 
be  in  the  morning. 

The  extent  of  local  preparation  will  vary  somewhat  with  the 
patient.  The  lower  class  patient  had  best  be  given  a  warm  tub  bath, 
in  the  afternoon  of  the  day  before  the  operation;  but  in  a  patient  who 
is  in  the  habit  of  bathing  himself,  such  active  cleansing  will  not  be 
required.  Some  patients  will  not  become  decently  clean  until  the 
bath  has  been  repeated  on  several  successive  days,  and  will  re-acquire 
dirt  at  the  least  opportunity.  When  the  demands  of  ordinary  clean- 
liness are  satisfied,  the  patient  may  rest  until  morning,  when  he  should 
be  shaved.  It  is  always  well  to  prepare  for  both  suprapubic  and  peri- 
neal wounds,  as  some  unforeseen  complication  may  make  it  advisable 
to  open  in  a  place  not  anticipated.  Hence  the  pubic  and  perineal 
hair  both  should  be  shaved;  the  skin  of  the  abdomen,  the  groins,  the 
genitals,  the  perineum,  and  the  anterior  and  inner  surfaces  of  the  thighs, 
should  all  be  thoroughly  washed  with  green  soap  and  hot  water,  then 
with  seventy  per  cent,  alcohol,  and  finally  with  corrosive  sublimate 
solution  (1:1000).  A  dry  sterile  dressing  should  then  be  applied  to 
the  abdomen  and  perineum,  and  should  remain  in  place  until  removed 
on  the  operating  table. 

Proust  laid  especial  emphasis  on  the  propriety  of  preparing  the 
urethra  of  every  patient  who  is  about  to  undergo  a  prostatectomy. 
He  thought  it  extremely  important  to  dilate  the  canal  by  the  passage 
of  sounds  for  some  days  before  the  operation,  so  as  to  insure  the  earliest 
possible  restoration  of  urethral  urination.  But  while  we  have  no  hesi- 
tation in  dilating  any  strictures  that  may  exist,  yet  we  think  that  the 
routine  dilatation  of  urethras  which  are  apparently  normal  except  for 
the  prostatic  obstruction  is  an  unnecessary  and  therefore  an  undesirable 
performance. 

18 


274 


Technique  of  Operations 


We  may  then  summarize  the  preparation  for  a  prostatectomy  as 
follows: 

Prehminary  treatment  following  the  principles  already  stated  and 
continued  for  a  time  sufficient  to  restore  the  vital  organs  to  their 
maximum  functional  capacity. 


Fig.   88. — Suprapubic  Operation. 
Skin  incision  exposing  the  sheath  of  the  right  rectus  muscle  close  to  the  median  line. 


On  the  day  before  the  operation  give  a  bath  in  the  afternoon; 
give  a  cathartic  before  supper;  for  supper  give  only  semisolid  food; 
the  bowels  should  be  opened  during  the  late  afternoon  or  early  evening; 
a  good  night's  rest  should  follow.  Fluid  may  be  taken  as  desired 
until  six  hours  before  the  operation. 

On  the  morning  of  the  operation  an  enema  is  to  be  given.     Then 


Preparing  the  Patient  275 

shave  and  surgically  cleanse  the  abdomen,  perineum,  etc.  Apply  the 
dressing,  and  wait  for  the  operation. 

Nitrous-oxide  oxygen  or  ether  is  to  be  preferred.  Chloroform  is 
sometimes  administered  to  patients  with  advanced  pulmonary  lesions 
but  with  relatively  sound  cardio-vascular  systems.  Anesthesia  in 
aged  individuals  will  often  tax  the  skill  and  abiUty  of  the  most  expert 
anesthetist;  this  is  especially  true  of  prostatics.  We  never  trust  these 
cases  to  the  relatively  inexperienced  Resident-Surgeon  who  is  neces- 
sarily lacking  in  the  skill  and  judgment  which  are  so  important  for 
the  successful  and  safe  administration  of  anesthetics,  and  especially 
of  nitrous-oxide. 

We  use  spinal  anesthesia  in  selected  cases.  In  using  this  agent, 
however,  it  is  very  important  not  to  give  it  where  there  is  low  blood 
pressure. 

Suprapubic  Prostatectomy. — The  patient,  being  well  covered  with 
blankets  and  sterile  sheets,  is  to  have  a  soft-rubber  catheter  passed  into 
his  bladder.  If  such  a  catheter  cannot  be  introduced  the  surgeon  should 
select  that  instrument  which  from  his  previous  experience  with  that 
patient  he  regards  as  most  likely  to  succeed  in  passing  the  obstruction. 
Through  this  catheter  the  bladder  is  to  be  evacuated,  and  rinsed  out 
with  hot  boric  acid,  saline  solution  (over  100°  F.)  or  oxycyanid  of 
mercury  solution  i  :  10,000  two  or  three  times,  or  until  the  fluid  returns 
clear.  About  120  cc.  of  this  fluid  should  remain  in  the  bladder, 
the  catheter  being  clamped  to  prevent  its  regurgitation. 

The  disadvantages  of  distention  with  air  have  already  been  referred 
to.  If  a  prehminary  cystostomy  has  been  done  the  bladder  is  irrigated 
through  the  drainage  tube  which  is  then  removed.  All  of  these  prehmi- 
nary procedures  are  completed  before  the  anesthesia  is  begun  especially 
if  nitrous-oxide  oxygen  anesthesia  is  to  be  given.  The  patient  is  then 
raised  into  a  moderate  Trendelenburg  position — about  thirty  degrees — 
and  the  suprapubic  region  uncovered.  The  surgeon,  standing  on  the 
right  of  the  patient,  then  makes  his  suprapubic  incision,  which  in  thin 
patients  need  not  exceed  six  cm.  in  length;  but  must  be  increased  up 
to  a  limit  of  perhaps  ten  to  twelve  cm.  where  the  abdominal  wall  is 
extremely  fat.  This  incision,  which  we  make  to  one  side  or  other  of  the 
linea  alba,  usually  to  the  right  side,  exposes  the  sheath  of  the  rectus 
muscle.  Its  lower  end  should  be  at  the  symphysis  pubis,  neither 
above  nor  below.  If  annoying  bleeding  occurs  from  veins  or  arterioles, 
these  should  be  clamped;  the  hemostatic  forceps  may  usually  be  re- 
moved as  soon  as  the  bladder  is  exposed,  and  will  therefore  not  be  in 
the  way  in  the  subsequent  steps  of  the  operation.    Vessels  of  any  size, 


276 


Technique  of  Operations 


which  are  rarely  met  with  near  the  middle  line  of  the  abdomen,  had  best 
be  ligated  at  once. 

The  sheath  of  the  rectus  muscle  is  then  opened,  and  its  fibres  sepa- 
rated, longitudinally  with  the  handle  of  the  scalpel,  from  their  pubic 
attachment  below,  up  to  but  not  quite  as  far  as  the  skin  incision  extends. 
We  regard  this  lateral  incision  as  of  distinct'advantage  in  decreasing 


Fig.  89. — Suprapubic  Operation. 
Separation  of  the  fibres  of  the  rectus  muscle  with  the  handle  of  the  scalpel. 

the  chances  of  the  formation  of  a  permanent  fistula.  The  wound  thus 
made  tends  to  close  spontaneously  as  soon  as  the  drainage-tube  is 
removed;  and  although  post-operative  hernia  in  this  situation  is  unusual, 
it  is  by  no  means  unknown. 

The  transversalis  fascia  and  preperitoneal  fat  are  then  divided  with 
the  scissors  in  the  Hne  of  the  skin  incision;  any  decrease  in  the  length 


Suprapubic  Prostatectomy 


277 


of  the  incision  should  be  made  at  the  expense  of  the  upper  end  of  the 
wound;  that  is  to  say,  the  surgeon  should  aim  to  work  down  on  the 
anterior  wall  of  the  bladder,  not  up  towards  its  peritoneal  surface. 
The  layer  of  vesical  fat  will  next  be  exposed,  lying  below  the  prevesical 
reflection  of  the  peritoneum.     The  surgeon  may  then  either  pass  the 


Fig.  90. — Suprapubic  Operation. 
The  bladder  has  been  exposed,  below  the  prevesical  fold  of  peritoneum,  which  can  be 
seen  across  the  upper  angle  of  the  wound.     A  tenaculum  steadies  the  bladder,  preparatory 
to  its  being  opened. 

fingers  of  his  left  hand  down  behind  the  pubis  to  the  pubo-prostatic 
ligaments,  and  draw  this  layer  of  fat  bodily  up  towards  the  abdominal 
end  of  the  wound,  or  snip  through  it  in  the  line  of  the  original  incision, 
with  his  blunt-pointed  scissors.  We  prefer  the  latter  course.  Retractors 
may  be  applied  to  each  side  of  the  wound,  and  aid  in  keeping  the  struc- 
tures to  be  divided  fairly  taut.    Any  hemostatic  forceps  which  were 


278  Technique  of  Operations 

used  to  clamp  bleeding  points  in  the  abdominal  wall  may  now  be 
removed,  since  it  will  be  found  that  such  vessels  have  ceased  to  bleed. 

The  large  veins  in  the  prevesical  fat  should  be  avoided  if  possible. 
If  the  surgeon  divides  any,  it  is  well  to  ligate  them  at  once.  If  possible, 
they  should  be  ligated  in  two  places  before  being  cut,  the  division 
between  two  ligatures  maintaining  the  wound  dry,  and  enabhng  the 
surgeon  to  see  clearly  the  field  of  operation. 

The  edges  of  the  wound  having  been  retracted,  a  small  piece  of 
moist  gauze  is  placed  above  the  bladder  and  with  a  third  retractor  the 
peritoneum  is  pulled  upward  thus  making  exposure  of  the  bladder,  divi- 
sion of  the  prevesical  fat,  and  opening  the  bladder  a  simpler  procedure. 

The  prevesical  fold  of  peritoneum  may  not  be  seen  in  these  opera- 
tions, the  Trendelenburg  position,  even  without  the  distention  of  the 
bladder,  allowing  it  to  recede  above  the  upper  limits  of  the  wound. 
If  it  is  seen,  it  is,  as  a  rule,  easily  recognized,  both  by  the  typical  appear- 
ance of  peritoneum  seen  elsewhere,  and  by  the  fact  of  its  being  a  trans- 
verse fold;  and  it  is  easily  detached  from  the  bladder  by  blunt  dissection. 
Should  it  unfortunately  be  opened,  it  should  at  once  be  sutured. 

The  bladder  is  recognized  by  its  blue  appearance  and  its  consist- 
ency. If  any  doubt  exists  as  to  its  identity,  it  will  be  sufficiently  mani- 
fested by  injecting  more  fluid  through  the  catheter.  There  are  often 
large  and  turgid  veins  on  its  surface. 

When  the  bladder  is  thus  exposed,  two  retention  sutures  may  be 
passed  through  its  outer  coats,  about  twelve  to  eighteen  mm. 
apart,  equidistant  from  the  proposed  line  of  incision,  and  in  its  upper 
third.  We  formerly  passed  these  sutures  through  the  whole  thickness 
of  the  abdominal  walls  as  well,  and  let  them  remain  at  the  conclu- 
sion of  the  operation,  thinking  thus  to  lessen  the  danger  of  extravasa- 
tion into  the  space  of  Retzius;  but  we  think  the  likelihood  of  this  danger  is 
overestimated,  and  we  have  had  more  fear  of  causing  an  injurious  ante- 
flexion of  the  bladder;  so  that  we  no  longer  intend  these  for  permanent 
sutures,  but  merely  to  act  as  guys  during  the  enucleation  of  the  prostate. 
If  it  is  difficult  to  pass  these  sutures,  on  account  of  the  depth  of  the 
wound,  one  may  be  made  to  suffice  by  placing  it  in  the  line  of  the  incision, 
at  the  upper  angle  of  the  wound.  Indeed,  we  now  find  it  quite  suffi- 
cient to  steady  the  bladder  with  a  tenaculum  until  the  finger  reaches 
the  prostate  and  then  to  remove  the  tenaculum  and  let  the  bladder  fall 
back  into  the  pelvis  during  the  enucleation. 

The  bladder,  being  thus  securely  fixed  in  the  wound,  is  to  be  opened 
by  an  incision  made  towards  the  pubic  symphysis,  and  extending  below 


Suprapubic  Prostatectomy  279 

it.  This  incision  in  the  bladder  walls  should  never  be  made  upwards, 
as  not  only  might  the  peritoneum  be  opened,  but  a  coil  of  intestine 
wounded  as  well.  It  is  inadvisable  to  make  an  incision  of  more  than 
25  to  40  mm.  in  length  in  the  bladder  wall,  and  the  left  index  finger  of 
the  surgeon  should  follow  the  knife  in,  so  as  to  palpate  the  inner  surface 
of  the  bladder,  the  prostate,  and  the  urethra,  before  all  the  fluid  has 
escaped.  A  much  more  accurate  idea  of  the  relations  of  the  various 
parts  is  attained  when  the  bladder  is  distended. 

The  table  may  now  be  replaced  in  the  horizontal  position. 

The  finger  should  first  seek  to  recognize  the  position  of  the  urethra 
with  its  contained  catheter.  The  outHnes  of  the  prostate  can  next  be 
determined,  the  presence  of  calculi  detected,  and  plans  made  for  the 
further  continuance  of  the  operation.  Any  calcuU  present  should  first 
be  removed,  with  forceps  or  scoop.  If  no  guy  sutures  have  been  retained 
in  the  bladder  it  is  best  not  to  remove  the  finger  from  its  interior  until 
the  completion  of  the  operation,  as  its  re-introduction  may  be  difficult 
if  the  abdominal  wound  is  deep.  If  a  large  calculus  is  found,  the  inci- 
sion in  the  vesical  wall  may  need  to  be  enlarged  before  the  stone  can 
be  safely  removed;  but  with  skill  even  large  stones  may  be  removed 
through  an  incision  of  little  more  than  25  mm.  In  very  many  cases 
retractors  must  be  employed  to  draw  apart  the  sides  of  the  abdominal 
wound  and  the  bladder  wall  before  the  prostate  can  be  satisfactorily 
exposed.  At  times  two  other  retractors  may  be  used  to  advantage, 
increasing   the  field  of  operation  in  its  longitudinal  diameter. 

If  a  pedunculated  prostatic  outgrowth  acting  as  a  ball-valve  against 
the  vesical  orifice  of  the  urethra  is  found,  it  should  be  twisted  off  with 
the  fingers,  or  its  pedicle  should  be  cut  through  with  scissors  or  bladder 
forceps.  If  no  other  urethral  obstruction  exists, — a  fact  which  can 
readily  be  determined  by  partially  withdrawing  and  re-inserting  the 
catheter, — the  operation  may  now  be  terminated,  and  the  bulk  of  the 
prostate  be  left  untouched.  Often,  however,  there  will  be  found  similar 
prostatic  tumors  projecting  into  and  obstructing  the  urethra,  which  are 
not  evident  from  the  cavity  of  the  bladder;  hence  the  great  importance 
of  making  sure  of  the  patulous  condition  of  the  urethra  before  de- 
ciding to  conclude  the  operation  by  a  partial  prostatectomy.  This  is 
a  point  which  was  much  insisted  upon  by  Belfield,  and  is  probably  the 
explanation  of  the  failure  of  so  many  of  the  early  suprapubic  prostatec- 
tomies to  effect  a  permanent  cure. 

At  the  present  time  but  few  operators  would  be  content  to  remove  a 
pedunculated  nodule  or  lobe. and  leave  the  prostate  undisturbed.     But 


280 


Technique  of  Operations 


we  insist,  there  are  some  few  cases  in  which  this  condition  exists,  in 
which  a  cure  can  be  effected  without  removal  of  the  prostate.  Doubt- 
less some  of  these  tumors  ari^e  from  the  subcervical  group  of  glands  and 
are,  therefore  extra-prostatic  in  origin,  which  fact  explains  the  success 
following  their  removal.  We  are  in  the  habit  of  making  a  careful 
bimanual  examination  of  the  prostate  in  these  cases,  with  the  index 


Fig.  91. — Suprapubic  Operation. 
The  bladder  has  been  opened,  and  by  the  use  of  retractors  the  field  of  operation  is 
exposed  sufficiently  to  show  the  enlarged  prostate  with  the  end  of  the  catheter  projecting 
from  the  vesical  orifice  of  the  urethra.     An  incision  has  been  made  in  the  vesical  mucous 
membrane  over  the  right  lobe  of  the  prostate,  down  to  its  capsuls. 

finger  of  one  hand  in  the  prostatic  urethra  and  the  index  finger  of  the 
other  hand  in  the  rectum.  By  this  means  any  irregularities  in  the 
shape  or  increase  in  size  of  the  gland  may  be  demonstrated,  and  if  a 
beginning  hypertrophy,  however  early,  is  found,  the  prostate  is 
removed. 

If  no  such  pedunculated  growth  exists,  or  if  a  complete  prosta- 


Suprapubic  Prostatectomy  281 

tectomy  is  indicated,  the  enucleation  of  the  prostate  is  begun.  This 
may  be  accomplished  in  one  of  several  ways;  no  one  method  is  appli- 
cable to  every  case.  In  the  majority  of  instances  we  find  the  intra- 
urethral,  or  as  it  is  sometimes  called,  extravesical  method,  preferable. 
Squier,  who  first  advocated  this  procedure,  recommends  that  the  roof 
of  the  urethra  be  broken  through  and  that  the  enlarged  lateral  lobes 
be  removed  separately  through  this  single  opening. 

We  have  found  it  advantageous  to  begin  the  enucleation  by  breaking 
through  the  mucosa  on  the  side  wall  of  the  urethra  usually  over  the 
most  prominent  part  of  the  prostate  and  on  a  plane  posterior  to  the 
coUiculus. 

With  the  manipulation  necessary  to  free  the  lateral  lobe  this  tear 
in  the  mucous  membrane  is  enlarged,  but  it  usually  extends  circum- 
ferentially  and  proximal  to  the  colHculus  so  that  the  anterior  portion  of 
the  prostatic  urethra,  including  the  colliculus  and  the  terminals  of  the 
ejaculatory  ducts,  is  not  destroyed.  Nature  aids  us  in  preserving  these 
structures,  as  Squier  has  shown,  because  they  are  but  loosely  attached 
to  the  prostate. 

If  the  finger  is  now  made  to  cross  behind  the  urethra  to  reach  the 
opposite  lobe  after  freeing  its  fellow,  there  is  little  danger  of  injury  to 
the  floor  of  the  urethra  especially  when  the  lateral  lobes  are  easily 
enucleable,  and  the  enucleation  of  these  lobes  is  done  separately.  This 
is  often  unavoidable,  however,  because  of  the  presence  of  nodules  beneath 
the  urethra.  These  may  take  origin  from  the  middle  lobe  tubules  or 
from  the  lateral  lobes;  in  either  event  destruction  of  the  proximal  part 
of  the  urethra  occurs  during  their  removal.  Care  should  be  taken  to 
remove  only  that  part  of  the  urethra  proximal  to  the  colliculus. 

In  cases  where  there  is  bilateral  and  symmetrical  enlargement  of  the 
lateral  lobes  in  the  absence  of  nodules  beneath  the  floor  of  the  urethra, 
the  hypertrophied  lobes  may  be  removed  separately  through  a  tear 
in  the  mucosa  of  the  roof  of  the  urethra  after  the  method  of  Squier. 

Ordinarily  the  details  of  the  enucleation  as  practised  in  our  clinic 
are  as  follows:  the  index  finger  is  introduced  into  the  prostatic  urethra 
which  is  thus  dilated;  care  being  taken  not  to  overstretch  the  parts. 
One  or  two  fingers  of  the  opposite  hand  are  inserted  into  the  rectum  for 
the  purpose  of  steadying  the  prostate.  The  mucous  membrane  on  the 
lateral  wall  of  the  urethra  covering  the  most  prominent  part  of  the  en- 
larged prostate  is  torn  through  on  a  plane  posterior  to  the  colliculus. 

The  finger  soon  finds  the  line  of  cleavage  and  this  is  followed  upward 
and  forward  thus  freeing  the  apex  of  the  lobe.     Next  the  finger  is 


282  Technique  of  Operations 

swung  around  the  upper  and  outer  surfaces.  Having  completed  this 
the  finger  is  again  passed  forward  and  an  attempt  is  made  to  free,  or,  as 
Squier  expresses  it,  "hook  back"  the  lobe  into  the  bladder.  Succeeding 
in  this,  it  only  remains  to  free  it  from  its  attachment  to  the  vesical 
mucosa;  this  is  usually  not  difficult. 

The  finger  is  re-inserted  into  the  urethra  and  into  the  cavity  whence 
the  lobe  came;  it  is  then  passed  across  the  roof  of  the  urethra,  if  we 
may  be  permitted  to  so  express  it,  and  the  remaining  lateral  lobe 
is  enucleated  in  exactly  the  same  manner. 

In  many  cases  it  is  found  after  freeing  the  first  lobe  that  a  sub- 
urethral portion  of  it,  or  in  some  instances,  an  attached  median 
lobe  enlargement  prevents  the  deHvery  of  the  otherwise  freed  portion 
into  the  bladder  cavity.  It  is  better  in  these  circumstances  to 
remove  the  gland  en  masse  at  the  same  time  making  every  attempt 
to]  spare  the  floor  of  the  urethra. 

Having  failed  to  deUver  the  lateral  lobe  into  the  bladder  cavity, 
the  finger  is  swung  around  and  behind  the  median  portion.  This 
brings  us  to  the  posterior  surface  of  the  opposite  lateral  lobe.  This  is 
dissected  free,  exactly  as  was  its  fellow  on  the  opposite  side,  except  that 
the  steps  of  the  procedure  are  reversed — the  posterior  and  outer  sur- 
faces being  freed  first. 

The  gland  may  then  be  hooked  back  into  the  bladder  cavity — not 
as  separate  lobes  but  as  a  single  trilobed  body.  The  final  step  in  its 
removal  is  completed  when  adhesions  to  the  vesical  mucous  membrane 
are  divided. 

With  proper  care,  the  anterior  part  of  the  prostatic  urethra  need  not 
be  destroyed. 

In  enucleating  the  prostate  from  the  vesical  side,  an  incision  long 
enough  to  admit  the  end  of  the  index  finger,  should  be  made  over  the 
more  prominent  of  the  two  lateral  lobes.  This  incision  should  run 
parallel  with  the  urethra,  and  is  usually  most  conveniently  made  with  a 
pair  of  scissors;  we  have,  however,  on  numerous  occasions,  simply 
scratched  through  the  vesical  mucous  membrane  with  the  finger-nail. 
The  surgeon  then  introduces  the  middle  and  index  fingers  of  his  right 
hand,  gloved,  into  the  patient's  rectum,  passing  his  arm  beneath  the 
flexed  thigh;  and  placing  his  thumb  against  the  perineum,  makes 
counterpressure  on  the  prostate,  and  raises  it  up  towards  the  enucleating 
finger.  The  larger  and  more  adenomatous  the  prostate,  the  easier  it  is 
for  the  surgeon  to  find  the  natural  line  of  cleavage  which  exists  between 
the  prostatic  capsule  and  its  sheath.     It  is  not  safe  to  go  too  wide  of  the 


Suprapubic  Prostatectomy  283 

prostate  in  the  endeavor  to  remove  it  all.  All  of  it  will  be  removed, 
except  perhaps  here  and  there  a  flake  off  the  outer  surface  of  its  capsule, 
by  clinging  close  to  the  adenomatous  organ  rather  than  by  going  off  on 
voyages  of  discovery  into  the  sheath.  In  other  words,  the  prostate  is 
to  be  removed  from  its  sheath,  not  the  sheath  from  the  prostate. 

The  finger  should  first  pass  to  the  outer  side  of  the  lateral  lobe  first 
attacked.  In  this  situation  the  attachment  of  the  prostate  to  its 
sheath  is  least  dense.  Then  the  finger  should  cautiously  but  not 
timidly  work  down  and  under  the  lateral  lobe,  towards  the  neighbor- 
hood of  the  posterior  commissure  and  the  ejaculatory  ducts.  Next 
the  posterior  and  inferior  surfaces  are  separated  from  the  sheath;  and, 
finally,  when  the  lobe  is  pretty  well  outlined,  the  finger  may  pass  along 
the  lateral  and  inferior  surfaces  to  the  apex,  and  free  it  from  the 
triangular  ligament. 

At  times  the  lateral  lobe  first  attacked  may  come  away  alone, 
leaving  the  urethra  still  attached  to  the  other  lateral  lobe.  More 
often  in  our  experience  the  original  incision  through  the  vesical 
mucous  membrane  has  torn  larger  during  this  enucleation,  and 
the  vesical  orifice  of  the  urethra  has  become  entirely  detached  by  the 
extension  of  the  tear  across  the  trigone  of  the  bladder.  Then  the 
enucleating  finger  will  pass  across  to  the  second  lobe,  often  as  it  does 
so  tearing  loose  the  ejaculatory  ducts  from  their  union  with  the  urethra, 
and  finally,  having  completed  the  enucleation  of  this  second  lobe,  will 
find  the  prostate  fully  detached  from  all  its  surrounding  structures 
except  where  the  urethra  annexes  it  to  the  triangular  ligament. 

At  this  stage  of  the  operation  either  one  of  two  things  happens — 
the  urethra  slips  out  from  the  centre  of  the  prostate,  remaining  still 
attached  to  the  triangular  ligament,  and  hanging  loose  like  the  empty 
finger  of  a  glove  (with  its  end  cut  off)  in  the  cavity  from  which  the 
prostate  has  been  enucleated;  or,  which  we  think  is  more  frequently  the 
case,  the  urethra  tears  off  at  the  triangular  ligament,  and  its  prostatic 
portion  is  removed  entire  in  the  centre  of  the  prostate.  We  do  not  see 
how  it  is  possible,  and  know  it  has  never  been  so  for  us,  to  leave  the 
prostatic  urethra,  with  the  attached  ejaculatory  ducts  in  place,  annexed 
at  both  ends — anteriorly  to  the  triangular  ligament,  posteriorly  to 
the  bladder  wall.  We  have  been  able  to  remove  the  entire  prostate, 
including  of  course  its  urethra,  through  the  one  original  incision  made 
through  the  vesical  mucous  membrane;  but  where  the  organ  is  very 
large  this  cannot  be  satisfactorily  done,  and  a  second  incision,  compar- 
able to  the  first,  must  be  made  over  the  other  lateral  lobe.     If  the 


284 


Technique  of  Operations 


anterior  commissure  of  the  gland  gives  way  during  these  manipulations 
it  is  theoretically  possible  to  swing  the  whole  prostate  (which  is  then 
merely  an  organ  with  the  urethra  lying  in  a  groove  on  its  upper  surface) 
across  beneath  the  urethra,  and  to  deliver  it  entire  through  one  or  other 


of  the  incisions  in  the  mucous  membrane  of  the  bladder;  but  even  thus, 
we  cannot  see  how  the  attachment  of  the  ejaculatory  ducts  can  be 
preserved,  in  the  Freyer  operation,  though  it  is  theoretically  possible 
for  the  prostatic  urethra  to  remain  intact,  traversing  the  cavity  from 


6 


2   E 


p<  ^   c 

O  a    c3 

^  I  i 

g  ^1 


Suprapubic  Prostatectomy  285 

which  the  prostate  has  been  removed,  much  as  a  resistant  artery  traverses 
a  phthisical  cavity. 

The  condition  of  the  parts  which  is  probably  the  most  usual  is 
shown  in  Figure  93  taken  from  one  of  Freyer's  patients  who  died 
two  hours  after  the  operation.  Here  two  tongue-like  processes  can 
be  seen,  representing  the  remains  of  the  urethra,  extending  down- 
wards from  the  vesical  mucous  membrane,  and  upward  from  the 
triangular  ligament;  while  between  and  below  these  can  be  seen  the 
ejaculatory  ducts,  torn  loose  from  all  connection  with  the  urethral  floor. 

The  technique  of  enucleating  the  prostate  just  described  is  essen- 
tially that  of  Freyer;  it  is  the  method  which  we  have  employed  for 
many  years  but  which  has  lately  been  discarded  largely  for  the 
intra-urethral  method  of  Squier.  The  latter  is  described  on  page 
300  et  seq.     Our  technique  isotherwise  as  just  described. 

When  the  prostate  has  thus  been  delivered  into  the  interior  of  the 
bladder,  the  tissues  left  between  the  rectal  and  vesical  hands  are  felt 
to  be  very  thin,  and  no  trace  of  remaining  prostatic  substance  can  be 
detected.  The  hand  is  then  withdrawn  from  the  rectum,  the  glove 
removed,  and  the  prostate  extracted  from  the  bladder  with  the  fingers  or 
with  suitable  forceps.  The  more  adenomatous  the  postrate,  the  more 
compressible  it  will  be,  and  the  vesical  incision  should  not  be  enlarged 
until  attempts  to  remove  the  prostate  have  failed. 

The  cavity  from  which  the  prostate  was  enucleated  will  now  be 
found  to  have  become  amazingly  reduced  in  size,  both  by  active  con- 
traction, and  by  pressure  from  the  surrounding  structures.  Bleeding 
may  be  free,  but  is  usually  only  moderate  in  amount,  and  readily  con- 
trolled by  the  hot  douche,  which  is  to  be  freely  applied  through  the 
suprapubic  wound. 

Should  this  fail  to  control  the  hemorrhage  another  plan  must  be 
tried.  Often  by  gauze  pressure  well  directed  against  the  oozing  area 
the  bleeding  may  be  checked.  But  if  the  hemorrhage  persists,  or  in 
case  of  secondary  hemorrhage,  continuous  pressure  must  be  applied. 
It  has  been  advised  to  apply  this  in  the  following  way:  a  number  of 
layers  of  gauze,  of  suitable  size,  are  stitched  together  at  their  centre; 
the  end  of  the  suture  is  left  long,  and  is  attached  to  the  intravesical  end 
of  the  catheter  which  has  been  lying  in  the  urethra  throughout  the 
operation,  or  which  is  to  be  introduced  if  not  already  in  place.  By  with- 
drawing this  catheter,  the  thread  will  follow,  and  will  press  the  attached 
gauze  firmly  against  the  vesical  orifice  of  the  urethra.  Care  should  be 
taken  that  this  gauze  does  not  occlude  the  ureteral  orifices. 


286 


Technique  of  Operations 


This  method  of  hemostasis  has  always  seemed  to  us  to  be  objection- 
able. When  the  gauze  becomes  soaked  through  with  urine  there  is  risk 
of  its  acting  merely  as  a  sponge,  and  thus  allowing  the  blood  to  ooze 
through  its  meshes.  A  safer  plan,  we  think,  is  to  pack  with  gauze  the 
cavity  from  which  the  prostate  has  been  enucleated,  and  then  to  suture 


Fig.  93. — Appearance  of  Parts  After  the  Completion  of  Freyer's  Opera- 
tion, Showing  the  Remnants  of  the  Prostatic  Urethra,  Attached  Below  to  the 
Triangular  Ligament  and  Above  to  the  Bladder.  Between  the  Divided  Ends  of 
THE  Urethra  are  seen  the  Remains  of  the  Ejaculatory  Ducts. — (Walker.) 

over  the  packing  the  mucous  membrane  forming  the  roof  of  the  cavity 
from  which  the  prostate  has  been  removed,  of  course  leaving  an  end  of 
the  gauze  long,  to  come  out  through  the  suprapubic  wound,  and  facili- 
tate its  removal.     The  suture  material  should  be  catgut,  and  the  pack- 


Hemostasis  287 

ing  may  remain  in  place  until  it  became  loosened  by  the  absorption 
of  the  catgut — usually  in  from  four  to  five  days.  Of  course,  if  this 
method  were  adopted  for  the  control  of  secondary  hemorrhage,  the 
patient  would  have  to  be  anesthetized  and  the  suprapubic  wound  en- 
larged. For  secondary  oozing  which  is  not  marked  irrigation  with  hot 
water  will  usually  be  found  an  efl&cient  hemostatic;  or  a  solution  of 
adrenalin  chloride  (i :  10,000)  may  be  used.  It  is  certainly  well  to  try 
the  effect  of  milder  measures  first,  and  not  resort  to  packing  injudi- 
ciously. Of  recent  years  it  has  been  our  practise  to  place  a  purse- 
string  suture  of  catgut  in  the  torn  edge  of  the  vesical  mucosa.  With  this 
suture  in  place  the  prostatic  bed  is  packed  with  gauze  in  the  manner 
just  described.  The  suture  is  then  tied,  thus  drawing  the  edges  of  the 
mucosa  together  over  the  packing  and  holding  it  securely  in  place. 
This  has  proved  a  most  efficient  method  of  controlling  bleeding  after 
prostatectomy. 

Since  adopting  the  intra-urethral  method  of  enucleating  the  prostate 
we  have  had  less  troublesome  bleeding.  In  the  cases  where  packing  has 
become  necessary  the  enucleation  of  the  prostate  has  been  beset  with 
difficulties.  These  have  been  cases  with  small  fibrotic  prostates  during 
the  removal  of  which  lacerations  of  the  mucosa  in  the  region  of  the 
vesical  outlet  have  occurred.  Packing  after  the  manner  just  described 
is  particularly  applicable  to  these  cases. 

When  the  urethral  mucosa  remains  practically  intact  the  arrest 
of  hemorrhage,  which  is  rarely  called  for  in  these  circumstances,  can 
be  accomplished  by  packing  gauze  into  the  remaining  funnel  of  mucous 
membrane  in  quite  the  same  manner  as  one  might  fill  the  finger  of  a 
glove.  The  pressure  thus  exerted  on  the  cavities  whence  the  lobes  of 
the  prostate  came,  is  sufficient  to  stop  all  dangerous  bleeding;  sutures 
are  unnecessary. 

Of  the  many  methods  proposed  for  controlling  hemorrhage  after 
suprapubic  prostatectomy  in  addition  to  the  one  just  described,  two 
alone  are  worthy  of  consideration. 

One  of  these,  advocated  by  Judd,  entails  careful  hemostasis  by 
suture  and  ligature  with  primary  closure  of  the  bladder.  This  method 
was  advocated,  and  practised  for  a  time,  by  the  late  John  B.  Murphy 
of  Chicago  but  was  later  discarded  by  him.  We  likewise  discarded 
this  method  after  experiencing  the  necessity  of  re-operation  to 
evacuate  a  bladder  filled  with  blood  clots.  The  advantages  in  time 
and  comfort  for  the  patient  to  be  gained  by  primary  closure  of  the 
bladder  are  more  than  offset,  in  our  judgment,  by  the  dangers  attending 
this  procedure. 


288  Technique  of  Operations 

Hagner  is  sponsor  for  the  other  method,  namely,  the  control  of 
bleeding  by  pressure  exerted  through  the  medium  of  a  distensible 
rubber  bag. 

The  Hagner  bag  has  been  modified  by  Pilcher  to  the  extent  that  a 
catheter  attachment  is  provided. 

This  method  is  especially  applicable  to  cases  in  which  the  two-stage 
operation  has  been  performed,  and  in  which,  for  any  reason,  haste  is 
vitally  necessary  for  the  control  of  bleeding  after  the  removal  of  the 
prostate.  We  do  not  advocate  this  method  for  cases  in  which  it  is  per- 
missible to  enlarge  the  wound  and  control  the  bleeding  by  gauze  pressure 
and  suture. 

As  soon  as  the  prostate  is  extracted  from  the  interior  of  the  bladder, 
the  urethral  catheter,  if  not  previously  withdrawn,  is  to  be  removed; 
and  a  long  rubber  tube  of  large  calibre — eight  to  ten  mm. — passed  in  to 
the  bladder  through  the  suprapubic  wound.  This  tube  should  be 
open  not  only  at  the  end,  but  should  be  provided  with  large  eyes  on 
its  sides  near  the  vesical  end;  since,  should  the  bladder  wall  come  in 
contact  with  the  distal  opening,  all  drainage  would  be  effectually 
prevented.  To  further  obviate  the  likelihood  of  any  such  obstruction 
We  do  not  pass  the  tube  to  the  bottom  of  the  post-prostatic  pouch,  nor 
do  we,  in  any  circumstances,  dismiss  the  patient  from  the  table  until 
it  is  evident  that  the  tube  is  clear  of  all  clots  and  other  obstructions, 
and  the  urine  or  intravesical  fluid  can  be  seen  distilling  from  its  further 
end  drop  by  drop. 

The  tube  should  project  from  the  bladder  cavity  for  a  distance  of 
several  centimetres ;  it  should  be  fitted  with  an  elbowed  glass  tube,  to 
which  in  turn  is  attached  rubber  tubing  leading  to  a  urinal  which  is  at- 
tached to  the  side  of  the  bed. 

The  anesthetic  may  be  stopped  as  soon  as  the  irrigation  of  the 
bladder  is  commenced;  and  by  the  time  the  patient  is  in  his  bed  he 
should  be  fairly  conscious  of  his  surroundings. 

The  suprapubic  tube  is  held  in  place  by  a  stitch  through  the  skin ; 
and  the  angles  of  the  wound,  when  this  is  large,  may  be  sutured,  but  if 
the  urine  is  foul  no  sutures  at  all  should  be  employed;  but  as  the  parietal 
peritoneum  has  a  tendency  at  times  to  prolapse  into  the  upper  angle  of 
the  wound,  one  suture  in  this  situation  may  be  necessary.  Separate 
catgut  sutures  should  be  used  for  the  sheath  of  the  rectus  muscle  and  for 
the  skin.  The  dressing,  of  sterile  gauze,  cut  so  as  to  fit  around  the  tube, 
and  each  piece  overlying  that  beneath  in  an  imbricated  manner,  should 
be  copious,  and  may  be  reinforced  with  absorbent  cotton.     Thus  what- 


Hemostasis 


289 


ever  urine  is  not  carried  of!  by  the  tube,  but  leaks  out  along  its  sides, 
will  be  quickly  absorbed  in  the  dressings,  and  will  not  trickle  over  the 
patient's  buttocks  and  clothing. 

The  further  end  of  the  tube  must  be  connected  with  a  suitable 
receptacle  below  the  level  of  the  patient's  bladder,  so  that  the  syphonage 


Fig.    94. — Suprapubic  Operation. 
In  case  of  persistent  hemorrhage  the  cavity  from  which  the  prostate  has  been  enucleat- 
ed is  packed  with  gauze,  and  the  margins  of  the  vesical  mucous  membrane  sutured  over  the 
packing  with  catgut. 

may  be  continuous.  If  this  detail  is  attended  to  there  will  be  no 
necessity  for  the  employment  of  a  vacuum  pump,  as  described  by  W.  G. 
Richardson  or  the  more  recently  described  vacuum  bottle  of  E.  G.  Davis. 
The  urinal  into  which  this  suprapubic  tube  drains  should  be  partly  filled 
with  some  antiseptic  or  deodorant  solution,  sufficient  in  depth  to  cover 

19 


290  Technique  of  Operations 

the  end  of  the  tube;  and  in  calculating  the  amount  of  urine  excreted 
the  quantity  of  fluid  already  in  the  urinal  must  be  subtracted. 

The  suprapubic  dressing  may  be  renewed  as  often  as  it  becomes 
saturated.     As  a  rule,  twice  daily  is  quite  frequently  enough. 

Should  there  be  much  shock  after  the  operation,  suitable  stimulation 
must  be  administered;  but  it  is  of  more  importance  to  prevent  shock, 
and  for  this  purpose  nothing  is  so  efficacious  as  external  heat.  The 
patient  may  be  surrounded  with  hot-water  bags  throughout  the  opera- 
tion in  many  cases  with  the  greatest  advantage,  or,  better  still,  be  placed 
on  a  hot-water  bed. 

On  the  day  following  the  operation,  and  once  each  subsequent  day, 
the  bladder  may  be  douched  through  the  suprapubic  wound.  This 
should  not  be  done  routinely  however;  if  the  drainage  is  perfectly 
satisfactory  and  the  bladder  cavity  is  free  from  large  blood  clots  there 
are  no  indications  for  douching  in  the  average  case.  Bladder  irriga- 
tions are  useful,  however,  in  patients  with  foul  cystitis. 

We  do  not  retain  a  catheter  in  the  urethra,  nor  do  we  pass  one  to 
irrigate  the  bladder  after  the  operation  until  this  can  no  longer  be 
accomplished  through  the  suprapubic  wound.  But  if  an  ammoniacal 
state  of  the  urine  develops  we  think  great  advantage  is  to  be  derived 
from  douching  the  bladder  through  the  urethra,  the  fluid  draining 
off  by  the  suprapubic  wound. 

For  the  purpose  of  intravesical  douching  in  these  cases  it  is  usually 
quite  sufficient  to  introduce  the  nozzle  of  the  syringe  into  the  urinary 
meatus,  there  being  no  necessity  to  pass  a  catheter  into  the  bladder, 
since  the  passive  resistance  of  the  urethra  can  readily  be  overcome  by 
fluid  pressure.  The  suprapubic  tube  may  usually  be  removed  on  the 
second  day  after  the  operation,  and  the  patient  encouraged  to  pass  his 
urine  in  the  natural  way;  but  there  is  no  objection  to  leaving  the  tube 
in  place  for  five  or  six  days  if  such  a  course  should  seem  desirable. 
Voluntary  micturition  commonly  returns  early  after  this  operation; 
and,  as  there  is  no  fear  of  a  sinus  persisting  the  patient  may  be  propped 
up  in  bed  on  the  fourth  or  fifth  day,  and  be  allowed  to  sit  in  a  chair  at  the 
end  of  a  week  or  ten  days  if  his  general  health  permits.  Indeed,  as  soon 
as  the  patient  feels  able  to  be  out  of  bed,  no  matter  how  few  days  have 
elapsed  since  the  operation,  we  think  he  should  be  allowed  to  be  up. 

Unless  something  should  indicate  the  existence  of  urethral  obstruc- 
tion, we  are  not  in  the  habit  of  passing  instruments  by  this  route  so 
long  as  the  suprapubic  wound  remains  available  for  the  daily  irrigation 
of  the  bladder.     Should,  however,  this  fail  to  show  any  signs  of  closing 


Post-operative  Treatment 


291 


Fig.  9S. — Suprapubic  Opebation. 
Pr^inage-tube  an4  dressing  in  placet 


292  Technique  of  Operations 

in  the  second  week,  we  think  it  proper  to  sound  the  urethra,  so  as  to 
ensure  against  the  formation  of  strictures.  We  do  not  regard  it  as  at 
all  impossible  for  strictures  to  form  as  a  result  of  the  removal  of  the 
prostatic  urethra;  but  we  think  the  injudicious  resort  to  instrumen- 
tation might  very  well  render  their  formation  more  probable.  When, 
however,  the  suprapubic  wound  has  closed,  which  it  commonly  does  in 
the  third  or  fourth  week,  we  consider  it  safe  to  irrigate  the  bladder 
through  the  urethra;  and  this,  we  think,  should  be  done  at  least  once  a 
week  for  some  months  after  the  operation,  unless  the  urine  sooner 
becomes  normal.  In  any  case,  the  regular  passage  of  a  full-sized 
sound  once  a  week  for  some  months  after  the  operation  can  be  productive 
of  no  harm,  and  should,  we  think,  be  advocated  in  most  cases,  especially 
where  a  tampon  has  been  employed  for  the  control  of  hemorrhage. 

Some  surgeons  have  found  that  the  suprapubic  wound  is  apt  to 
re-open  once  or  twice  before  finally  healing;  but  this  has  not  been  our 
experience  except  in  the  rarest  instances. 

Secondary  hemorrhage  and  the  means  of  controlling  it  have  already 
been  referred  to;  but  we  think  it  important  to  call  attention  to  looseness 
of  the  bowels  as  a  cause  of  this  complication.  Every  time  the  bowels 
are  opened  the  granulating  wound  is  disturbed,  and  the  liability  to 
bleeding  increased.  Hence  diarrhea  should  be  avoided,  and  where 
sUght  oozing  persists  it  may  be  well  to  try  the  effect  of  opium  or  pare- 
goric before  more  strenuous  measures  are  resorted  to.  Secondary 
hemorrhage  has  been  known  to  occur  after  the  passage  of  the  rectal 
tube.  Care  must  be  taken,  therefore,  in  giving  enteroclysis  lest  the 
insertion  of  the  tube  cause  injury  to  the  prostatic  bed. 

The  patient's  usual  diet  and  mode  of  life  may  be  resumed  as  rapidly 
as  his  convalescence  will  permit;  but  he  should  pay  particular  attention 
to  the  state  of  his  kidneys  and  urine  for  many  months  after  the  operation. 
He  should  be  encouraged  to  drink  all  the  water  possible  from  the  instant 
his  stomach  becomes  retentive  after  recovery  from  the  anesthetic; 
this  is  the  surest  method  of  preventing  uremic  conditions.  The  appear- 
ance of  hiccough  and  nausea  following  the  recovery  from  anesthesia, 
particularly  if  a  small  amount  of  urine  is  being  excreted,  is  indicative 
of  a  mild  degree  of  uremia,  and  should  be  promptly  met  by  medical 
measures.  It  is  not  our  practice  to  resort  at  once  to  agents  such  as 
calomel,  sparteine,  cafiFeine,  etc.,  after  operation,  but  to  immediately 
wash  out  the  stomach  with  the  stomach-tube,  this  being  a  far  more 
effective  remedy  for  hiccough  than  any  antispasmodic  drug;  we  then 
introduce  into  the  stomach  45  to  60  cc.  of  Glauber's  salt  in  concentrated 


Two-Stage  Prostatectomy  293 

solution.  Where  the  stomach  is  empty  the  solution  soon  finds  its 
way  into  the  small  intestine,  and  in  a  short  time  bowel  action  is 
obtained.  We  have  found  this  of  more  service  than  any  other  agent. 
Should  further  treatment  be  required,  however,  rectal,  subcutaneous, 
or  intravenous  infusions  of  decinormal  saline  solution  should  be 
employed,  and  other  appropriate  treatment  should  be  instituted,  as 
already  indicated. 

SUPRAPUBIC  PROSTATECTOMY— THE  TWO-STAGE  OPERA- 
TION 

In  speaking  of  the  methods  of  choice  in  the  treatment  of  the  several 
groups  into  which  prostatics  may  be  more  or  less  definitely  separated 
on  pathological  grounds,  we  defined  very  clearly  our  belief  regarding 
the  two-stage  operation. 

This  discussion  needs  no  reiteration  and  we  will  proceed  therefore, 
with  descriptions  of  the  most  satisfactory  methods  of  performing  cys- 
tostomy  preliminary  to  removal  of  the  prostate. 

In  performing  a  cystostomy  for  preliminary  drainage  of  the  bladder 
the  technique  which  we  employ  dififers  but  little  from  that  followed  in 
opening  the  bladder  in  the  one-stage  operation,  except  insofar  as  the 
length  of  the  incision  is  concerned,  and  the  degree  of  exposure  of  the 
space  of  Retzius  and  of  the  anterior  bladder  wall. 

Our  aim  in  doing  a  preliminary  cystostomy  is  to  open  the  bladder  as 
near  to  its  summit  as  possible,  to  make  the  opening  of  sufl&cient  size 
to  permit  of  digital  exploration  of  the  bladder  cavity  and  of  the  removal 
of  any  calculi  that  may  be  present,  to  provide  adequate  drainage,  and, 
finally,  to  perform  the  operation  in  such  manner  that  the  tissues 
surrounding  the  incision  will  be  disturbed  as  little  as  is  consistent  with 
the  proper  performance  of  the  operation. 

To  determine  the  proper  position  for  the  drainage  tube  it  is  advisable 
to  locate  the  line  of  reflection  of  the  peritoneum  from  the  bladder  wall. 
In  some  cases  it  will  be  found  necessary  after  opening  into  the  bladder 
cavity  either  to  enlarge  the  opening  in  an  upward  direction  or  to  make 
an  entirely  new  opening  at  a  higher  level  so  that  the  drainage  tube 
emerges  from  the  bladder  near  its  summit.  A  cystostomy  opening 
for  permanent  drainage  is  placed  near  the  bladder  outlet;  here  our  pur- 
pose is  quite  the  contrary  since  the  more  distant  the  opening  is  from  the 
neck  of  the  bladder  the  more  quickly  will  the  fistula  close  after  the 
removal  of  the  prostate. 


294  Technique  of  Operations 

For  preliminary  drainage  we  prefer  a  tube  of  large  diameter,  as 
large  as,  or  even  larger  than  the  one  used  for  drainage  after  prostatec- 
tomy. In  some  few  cases  a  small  dePezzer  catheter  after  the  method  of 
Pilcher  is  desirable.  This  is  done  especially  in  cases  of  acute  retention 
with  enormously  distended  bladders.  If  immediate  operation  becomes 
necessary  owing  to  the  impossibiUty  of  catheterization,  the  introduction 
of  a  dePezzer  catheter  into  the  bladder  through  a  suprapubic  wound 
under  local  anesthesia  is  a  matter  of  commendable  simpUcity.  The 
operation  may  be  performed  quickly;  it  provides  adequate  drainage  to 
relieve  the  dangerous  back  pressure  on  the  kidneys,  and  it  provides  an 
easy  and  efficient  means  of  intermittent  relief  of  the  abnormally  high 
intravesical  pressure.  This  method  we  believe  is  superior  to  the 
trocar  and  cannula  method  of  Lower  which  suggests  itself  as  particu- 
larly apphcable  to  this  group  of  cases.  The  after-results,  however, 
leave  something  to  be  desired  as  far  as  the  ease  of  subsequent  removal 
of  the  prostate  is  concerned. 

FIRST  STAGE— PRELIMINARY  CYSTOSTOMY 

The  average  patient  who  is  subjected  to  the  two-stage  operation  in 
our  clinic  is  a  poor  operative  risk;  this  is  true  certainly  at  the  time  of 
the  preliminary  drainage  operation.  For  this  reason  it  is  advisable  to 
use  local  anesthesia  in  many  instances.  We  prefer,  however,  nitrous 
oxide,  oxygen  or  ether  anesthesia  when  there  are  no  special  contra- 
indications to  their  use.     We  have  practically  discarded  spinal  analgesia. 

For  local  anesthesia  we  use  novocaine  in  solutions  of  3^^oo  o^}'ioo 
strength,  the  stronger  solution  being  used  in  the  skin  and  bladder  wall. 

In  the  absence  of  very  definite  contra-indications  to  their  adminis- 
tration, morphine  sulphate  gr.  H  s-nd  atropine  sulphate  gr.  Koo  are 
given  hypodermatically  one-half  hour  before  operation.  Scopolamin 
gr-  }ioo  a-nd  morphine  gr.  }-q  may  be  given  before  operation  with  gratify- 
ing results.  We  have  seen  no  harm  result  from  the  judicious  use  of 
these  drugs  in  combination. 

The  patient  is  prepared  for  operation  in  the  usual  manner,  a  catheter 
is  introduced  into  the  bladder  and  the  latter  distended  with  a  solution 
of  warm  boric  acid,  oxycanid  of  mercury  (i-io,ooo)  or  other  antiseptic. 
The  technique  is  essentially  the  same  whether  the  cystostomy  is  per- 
formed under  local  or  general  anesthesia  except  as  regards  the  intro- 
duction of  the  local  anesthetic  into  the  tissues.  We  will  describe  the 
use  of  local  anesthesia  in  some  detail. 


Preliminary  Suprapubic  Cystostomy  295 

The  instrument  tray  should  contain,  in  addition  to  the  usual  instru- 
ments, a  number  of  syringes,  fitted  with  sharp  needles  of  small  calibre 
and  filled  with  novocain  solution  of  the  desired  strength. 

The  injection  of  novocain  solution  (Koo)  is  begun  at  a  point  about 
ten  centimetres  distant  from  the  symphysis  pubis  and  about  one  cm. 
to  midUne.  Beginning  at  this  point  the  injections  are  continued  in  a 
straight  line  downward  to  the  top  of  the  pubic  bone.  The  skin  and 
subcutaneous  tissues  are  included  in  this  primary  Une  of  analgesia. 
An  incison  is  then  made  down  to  the  rectus  sheath.  The  latter  is 
infiltrated  and  is  then  incised  in  Hne  with  the  skin  incision.  The  muscle 
tissues  and  underlying  transversalis  fascia  are  injected  with  a  weaker 
solution  of  novocain,  the  muscle  fibres  are  then  separated  and  the  fascia 
is  incised.  The  prevesical  tissues  are  now  exposed.  These  are  sepa- 
rated by  blunt  dissection,  and  only  insofar  as  is  necessary  to  expose  the 
line  of  peritoneal  reflection  from  the  bladder,  and  enough  of  the  latter 
to  permit  cystostomy.  The  cystostomy  opening  is  made  of  sufficient 
size  to  admit  the  introduction  of  the  drainage  tube.  The  space  of 
Retzius  is  exposed  during  these  manipulations  but  its  contents  are  but 
little  disturbed.  No  difficulty  is  experienced  in  recognizing  the  bladder 
wall  which  is  easily  distinguished  from  other  tissues  and  structures  by 
the  large  and  tortuous  veins  coursing  over  its  surface,  for  the  most 
part  in  an  upward  and  downward  direction. 

Having  located  the  summit  of  the  bladder,  a  small  quantity  of  the 
novocain  solution  is  injected  near  to  the  line  of  the  peritoneal  reflection- 
and  at  this  point  the  bladder  wall  is  grasped  by  tenaculum  forceps. 
Gentle  traction  is  exerted  in  an  upward  direction,  using  the  tenaculum 
to  steady  the  bladder  wall,  and  the  anesthetic  solution  is  injected  in  a 
line  extending  downwards  for  a  distance  of  approximately  five  cm. 
The  bladder  cavity  is  then  opened,  the  size  of  the  opening  being  made 
sufficient  to  admit  only  the  index  finger.  This  is  accomplished  by  intro- 
ducing the  knife,  with  its  cutting  edge  turned  towards  the  pubic  bone, 
into  the  bladder  cavity  at  a  point  just  below  where  the  bladder  wall  is 
grasped  by  the  forceps. 

The  finger  is  immediately  introduced  into  the  bladder  cavity  acd 
acts  as  a  plug  to  prevent  the  escape  of  urine,  the  examination  of  the 
interior  of  the  bladder  being  more  easily  and  satisfactorily  made  when 
the  viscus  is  distended.  It  must  first  be  determined  whether  the  open- 
ing is  properly  placed  in  relation  with  the  summit  of  the  bladder. 
If  placed  too  low,  the  peritoneum  must  be  carefully  dissected  away 
and  the  incision  enlarged  upward,  or  in  some  instances  an  entirely  new 


296 


Technique  of  Operations 


opening  must  be  made.  Digital  examination  of  the  interior  of  the 
bladder  is  made  before  enlarging  the  opening.  The  post-prostatic 
pouch  is  searched  for  calculi  and  if  the  cystoscopic  examination  revealed 
the  presence  of  diverticula  the  attempt  is  made  to  explore  their  cavities ; 
the  characteristics  of  the  intravesical  portion  of  the  prostate  next 
engage  our  attention. 

If  calculi  are  found  the  bladder  incision  is  enlarged  to  the  required 
dimensions  and  they  are  then  removed;  otherwise  the  incision  is 
enlarged  only  to  a  size  sufficient  to  admit  a  large  Freyer,  or  a  Marion 


Ca1F|eter. 


Fig.  96. — The  dePezzer  Catheter  in  the  Proper  Position  for  Preliminary  Drain- 
age.— {Pilcher,  Cabot's  Urology.) 


drainage  tube.  The  latter  is  anchored  by  a  single  suture  of  chromic 
catgut  to  the  incisional  margin  and  the  opening  is  closed  tightly  around 
the  tube.  The  latter  is  made  to  emerge  from  the  upper  angle  of  the 
incision. 

We  attach  considerable  importance  to  the  level  at  which  the  end  of 
the  drainage  tube  is  placed  in  relation  to  the  bottom  of  the  postprostatic 
pouch.  It  should  almost  touch  the  bladder  wall  to  insure  complete 
siphonage  of  its  contents. 

The  bladder  with  the  drainage  tube  in  position  is  permitted  to  fall 
back  into  the  pelvic  cavity  and  the  incision  is  closed  by  continuous 
catgut  suture  of  the  rectus  sheath  and  through  and  through  sutures  of 


Preliminary  Suprapubic  Cystostomy  297 

silkworm  gut.  It  is  our  practise  to  anchor  the  badder  to  the  rectus 
muscle  by  a  catgut  stitch  in  many  cases. 

The  position  of  the  drainage  tube  in  its  relations  with  the  abdominal 
wall  is  determined  after  the  bladder  has  been  allowed  to  fall  back  into 
the  pelvic  cavity,  when  if  the  tube  is  moderately  rigid,  it  will  naturally 
assume  the  proper  position. 

The  space  of  Retzius  need  not  be  drained  if  care  be  taken  not  to 
lacerate  its  fibro-fatty  contents.  But  carrying  a  piece  of  rubber  drain 
down  to  the  space  can  do  no  harm. 

We  prefer  a  drainage  tube  of  very  large  cahber,  25  mm.  in  diameter, 
for  routine  use.  In  certain  cases,  as  previously  mentioned,  in  which 
it  is  desirable  to  establish  drainage  in  the  shortest  possible  time  and 
in  which  prolonged  drainage  will,  in  all  likelihood,  be  necessary, 
we  sometimes  use  a  dePezzer  catheter,  or  the  Pilcher  modification  of  this 
instrument. 

This  technique  as  devised  by  Pilcher  who  advises  it  for  routine  use 
in  the  two-stage  operation,  will  be  described  in  detail  later;  suffice  it 
to  mention  here  a  few  details  in  its  use  which  we  have  found  advanta- 
geous in  cases  of  acute  retention. 

Under  local  anesthesia  the  greatly  distended  bladder  is  exposed  by 
as  limited  a  dissection  as  is  possible.  In  these  cases  there  is  little  or  no 
danger  of  wounding  the  peritoneum  and  there  is  likewise  little  danger 
of  placing  the  bladder  incision  too  low. 

Having  exposed  the  bladder  wall,  the  button-h'ke  end  of  the  dePezzer 
catheter  is  folded  and  grasped  in  the  jaws  of  a  pair  of  small  dressing 
forceps  and  its  distal  end  plugged.  The  scalpel  with  its  cutting  edge 
turned  downwards  is  then  quickly  plunged  through  the  bladder  wall 
and  immediately  the  dressing  forceps  carrying  the  catheter  are  intro- 
duced through  the  opening  into  the  bladder  cavity.  The  forceps  are 
opened,  thus  releasing  the  catheter,  and  are  then  removed.  The  button- 
like end  of  the  catheter  is  drawn  tightly  against  the  bladder  wall,  thus 
effectually  plugging  the  opening  so  that  practically  no  urine  escapes. 

If  the  incision  is  not  too  large,  it  is  unnecessary  to  use  sutures  except 
to  anchor  the  tube  to  the  bladder  wall.  The  wound  is  then  closed  in 
the  usual  manner. 

The  bladder  is  gradually  emptied  by  removing  the  plug  from  the 
catheter  from  time  to  time.  If  the  patient's  condition  is  good  he  may 
be  lifted  out  of  bed  on  to  a  chair  the  following  day.  This  not  only 
minimizes  the  dangers  of  pulmonary  congestion  and  senile  pneumonia, 
but  the  patient  is  impressed  with  the  apparent  innocuousness  of  the 


298  Technique  of  Operations 

operation  so  that  he  will  undergo  the  second  stage  without  fear  and 
in  full  confidence  of  his  ability  to  "get  well."  The  bladder  drainage 
may  be  continued  for  a  month  or  more  without  leakage  of  urine  and 
under  circumstances  that  are  ideal  for  repeated  functional  kidney 
studies,  and  if  subsequent  removal  of  the  prostate  is  contra-indicated, 
the  dePezzer  catheter  may  be  removed  and  a  silver  cannula  substituted 
for  it  as  a  means  of  permanent  drainage. 

SECOND    STAGE— REMOVAL    OF   THE   PROSTATE    GLAND 

Having  determined  the  fitness  of  the  individual  for  prostatectomy 
he  is  again  prepared  for  operation  in  the  usual  manner.  The  bladder 
is  thoroughly  irrigated  through  the  tube  with  a  warm  solution  of  oxy- 
cyanid  of  mercury  (1-10,000),  before  the  patient  is  brought  to  the 
operating  room.  For  anesthesia  we  choose  either  nitrous-oxide  oxygen 
or  ether.  If  the  second  stage  succeeds  the  cystostomy  operation  within 
a  period  of  ten  days  the  sutures  above  the  drainage  tube  are  not  removed. 
If  a  longer  period  of  time  has  elapsed  the  stitches  will  have  been  removed 
and  the  wound  is  firmly  healed.  It  will  then  be  necessary  to  enlarge 
the  wound  downward;  this  is  especially  true  if  a  dePezzer  catheter 
has  been  employed  for  drainage.  In  cases  in  which  a  very  large  tube 
has  been  used,  digital  dilatation  of  the  opening  usually  gives  ample  room 
for  the  enucleation  of  the  prostate  although  some  difficulty  may  be 
experienced  in  delivering  the  freed  prostate  from  the  bladder  cavity, 
indeed,  it  is  necessary  in  some  instances  either  to  enlarge  the  opening 
or  to  section  an  unusually  big  prostate  before  it  can  be  brought  out 
of  the  bladder  cavity. 

Having  removed  the  drainage  tube  and  provided  an  opening  of 
sufficient  size,  the  removal  of  the  prostate  is  effected  according  to  the 
principles  already  described. 

The  second  stage  of  a  two-stage  prostatectomy  differs  only  in  minor 
details  from  the  one-stage  operation,  except  as  concerns  the  enlarge- 
ment of  the  wound  and  in  the  treatment  of  complications  of  which 
hemorrhage  is  the  most  important.  Hemorrhage  is  one  of  the  com- 
monest causes  of  death  after  prostatectomy  and  in  the  vast  majority 
of  cases  it  is  controllable.  Patients  rarely  die  as  the  result  of  the  loss 
of  blood  during  the  operation;  it  is  the  bleeding  that  occurs  after  the 
patient  is  returned  to  the  ward  or  recovery  room  that  proves  fatal. 
The  time  to  control  this  bleeding  is  at  the  time  of  operation,  not  after 
several  hours  of  waiting  to  see  whether  it  will  stop  spontaneously.  It  is 
absolutely  unjustifiable  to  send  a  patient  from  the  operating  table  who 


Secondary  Prostatectomy  299 

is  bleeding;  prostatic  surgery  offers  no  exception  to  this  surgical 
principle. 

Serious  bleeding  is  less  likely  to  follow  prostatectomy  in  cases  which 
have  had  preliminary  drainage  because  of  the  relief  of  congestion 
incident  to  such  drainage.  It  does  occur,  however,  and  active  measures 
must  sometimes  be  taken  to  arrest  it.  Our  technique  does  not  differ  in 
this  respect  from  that  employed  in  the  ordinary  prostatectomy;  the 
wound  is  opened  widely,  the  bleeding  area  is  exposed,  and  if  possible 
the  bleeding  vessel  or  vessels  are  ligated.  Failing  in  this  the  prostatic 
bed  is  packed  with  a  strip  of  gauze,  one  end  of  which  is  brought  out 
through  the  suprapubic  opening.  The  gauze  is  held  securely  in  place 
by  a  purse  string  suture  in  the  mucosa  surrounding  the  vesical  side  of 
the  prostatic  bed. 

This  procedure  is  attended  with  some  difficulties  in  patients  who 
have  had  preUminary  drainage,  but  we  much  prefer  it  to  any  of  the 
other  methods  proposed.  Some  surgeons  prefer  not  to  enlarge  the 
opening  and  are  wilHng  to  trust  to  the  pressure  of  a  Hagner  or  Pilcher 
bag  for  the  control  of  bleeding.  The  descriptions  of  the  latter  methods 
together  with  certain  other  variations  in  technique,  are  given  elsewhere. 

The  after-care  of  patients  operated  upon  in  two  stages  differs  not 
at  all  in  our  clinic  from  that  practised  after  a  one-stage  prostatectomy. 

Suprapubic  Prostatectomy^Modifications  in  Technique. — The  tech- 
nique of  enucleation  of  the  prostate  gland  has  undergone  many  modifica- 
tions especially  in  respect  to  the  manner  of  beginning  the  enucleation. 
It  will  be  recalled  that  Freyer  recommended  that  an  incision  be  made 
parallel  with  the  urethra  through  the  vesical  mucosa  covering  the  most 
prominent  part  of  the  intravesical  projection  and  beginning  the  enu- 
cleation at  this  point.  Attention  was  called  to  the  fact  that  this  por- 
tion of  the  prostate  is  covered  merely  by  mucous  membrane  beneath 
which  lies,  what  Freyer  believes  to  be,  the  true  capsule  of  the  gland. 

Fuller  of  New  York  had  previously  recommended  that  a  cut  be  made 
through  the  median  lobe  or  bar  with  scissors,  and  that  this  incision  ex- 
tend from  the  lower  margin  of  the  internal  vesical  opening  of  the  urethra 
backward  for  an  inch  to  an  inch  and  a  half.  Through  an  incision  of  this 
kind  he  did  what  was  undoubtedly  the  first  complete  prostatectomy. 
Freyer  however,  popularized  the  operation  and  modified  it  to  the  ex- 
tent that  the  incision  was  placed  over  the  most  prominent  part  of  the 
intravesical  projection.  He  also  recommended  that  the  finger  nail 
instead  of  the  scissors  be  used  for  cutting  through  the  vesical  mucosa. 

We  soon  adopted  the  technique  as  described  by  Freyer  but  found  it  ad- 


300 


Technique  of  Operations 


vantageous  to  make  a  second  incision  over  the  other  lateral  lobe  when 
there  was  considerable  intravesical  projection.  Other  modifications  in 
the  technique — for  the  most  part  of  minor  importance — were  evolved. 
Perhaps  the  most  important  of  these,  certainly  the  one  that  has  caused 
most  discussion,  was  our  advocacy  of  simple  extirpation  of  pedunculated 
median  lobes  leaving  the  bulk  of  the  prostate  untouched.  This  of 
course  was  the  principle  of  the  McGuire  operation.  As  we  have  ex- 
plained, it  is  rarely  indicated  for  the  reason  that  isolated  prostatic 
nodules  giving  rise  to  urethral  obstruction  seldom  occur ;  when  they  do 
occur  and  the  prostate  is  not  hypertrophied  throughout,  the  latter, 
we  repeat  should  not  be  disturbed. 


Fig.  97. — Intra-urethral  Enucleation  of  the  Prostate. 
Step  I.     (/.  Bentley  Squier,  Surgery,  Gynecology  and  Obstetrics,  1912,  xv,  599.) 


After  meeting  with  certain  cases  in  which  folds  or  tabs  of  mucous 
membrane  caused  obstruction  to  urination  after  prostatectomy  it  was 
proposed  that  an  incision  be  made  through  the  vesical  mucosa  covering 
the  intravesical  portion  of  the  prostate  in  an  encircling  manner;  to  this 
the  fanciful  name  of  circumcision  of  the  vesical  outlet  was  given. 

The  technique  of  the  subsequent  enucleation  of  the  prostate  differed 
to  some  extent  with  individual  operators  but  the  fundamental  principles 


Modifications 


301 


were  quite  the  same  as  those  enumerated  by  Fuller  and  Freyer.     These 
we  have  already  described. 

The  fact  that  the  so-called  hypertrophied  prostate  really  consists  of 
a  group  of  adenomata  or  rather,  adenomatous  masses,  more  or  less 
firmly  bound  together  and  originating  within  the  prostate  gland,  must 
be  borne  in  mind  during  the  enucleation.  If  our  conception  of  the 
pathology  of  the  condition  is  correct,  these  nodules  have  formed  a  false 
capsule  as  the  result  of  pressure.  This  capsule  consists  of  compressed 
prostatic  tissue  which  has  not  participated  in  the  neo-formation,  and  of 
the  peripheral  fibromuscular  stroma  or  true  capsule.  Within  the  en- 
velope and  more  or  less  loosely  attached  to  it  lies  the  part  of  the  prostate 
that  will  be  removed.  Outside  of  the  envelope  and  almost  inseparably 
bound  to  it  is  the  sheath  of  the  prostate  which  is  merely  a  visceral  pro- 
longation of  the  pelvic  fascia. 


Fig.  98. — Intra-urethral  Enucleation  of  xiiii  1'rustaxe. 
Step  2.    (/.  Benlley  Squier,  Surgery,  Gynecology  and  Obstetrics. 

This  sheath  is  deficient  in  the  region  of  the  vesical  outlet  and  through 
this  hiatus  the  enlarging  prostate  enters  the  bladder.  The  major 
pressure  on  the  true  capsule  and  on  the  compressed,  but  otherwise  nor- 
mal prostatic  tissue,  is  exerted  here,  and  it  is  reasonable  to  suppose  that 
these  tissues  undergo  partial  if  not  complete  atrophy,  so  that  the  tumor 
itself  comes  to  be  directly  beneath  the  vesical  mucosa. 


302 


Technique  of  Operations 


This  fact  explains  also  why  the  line  of  cleavage  between  the  false 
capsule  and  the  tumor  mass,  which  it  surrounds,  is  sometimes  found 
with  difficulty  when  the  enucleation  is  begun  from  the  vesical  side. 

The  sphincter  muscle  is  not  directly  attached  to  the  tumor  but  is 
separated  from  the  latter  by  such  parts  of  the  false  capsule  as  exist  in 
this  area. 


Fig.  99. — Intra- URETHRAL  Enucleation  of  the  Prostate. 
Step  3.     (/.  Bentley  Squier,  Surgery,  Gynecology  and  Obsetrics.) 

If  we  accept  the  views  of  Tandler  and  Zuckerkandl,  namely,  that  the 
great  majority  of  cases  of  prostatic  hypertrophy  begin  in  the  middle 
lobe  tubules  and  remain  localized  to  this  structure,  and  that  the  lateral 
posterior  lobes  suffer  pressure  atrophy,  we  must  materially  change  our 
technique  relative  to  the  steps  in  the  enucleation. 

It  has  been  established  beyond  dispute  largely,  as  the  result  of 
Lowsley's  investigations,  that  the  posterior  lobe  tubules  which  lie 
posterior  to  the  ejaculatory  ducts,  rarely,  if  ever,  take  part  in  benign 
hypertrophy.  The  ejaculatory  ducts  traverse  the  prostate  gland  on  a 
plane  lying  between  the  posterior  lobe  tubules  behind  and  the  middle 
and^lateral  lobe  tubules  in  front.     If,  as  is  generally  believed,  the 


Squier's   Technique 


303 


latter  structures  alone  are  involved  in  the  hypertrophic  processes,  it 
follows  that  the  ejaculatory  ducts  will  be  displaced  posteriorly  and  will 
not  be  disturbed  by  prostatectomy,  provided  that  part  of  the  floor  of  the 
urethra  anterior  to  and  including  the  verumontanum  is  preserved. 
These  ducts  open  into  the  sides  of  the  anterior  declivity  of  the 
verumontanum . 

In  the  light  of  our  present  knowledge  this  then  is  the  ideal  to  be 
attained,  namely,  to  remove  the  prostate  or  rather  to  remove  the  adeno- 


1^: 

i 

^ 

^ 

J 

W^ 

^ 

^^ 

,v„ 

I 

I 

r 

-n 

n 

X 

''^^^ 

J 

Fig.  100 — Intra- URETHRAL  Enucleation  of  the  Prostate. 
Step  4.     (/.  Benlley  Sqiiier,  Surgery,  Gynecology  and  Obstetrics.) 

ma-Uke  masses  originating  in  the  prostate  without  destroying  the  ejacu- 
latory ducts  or  that  portion  of  the  floor  of  the  urethra  into  which  they 
open.  That  this  is  always  possible,  we  much  question;  that  it  is  the 
result  to  be  aimed  at  is  undoubted. 

In  describing  the  enucleation  of  the  prostate  by  the  Freyer  method 
some  lines  were  devoted  to  an  argumentative  consideration  of  the  possi- 
bility or  impossibility  of  sparing  the  ejaculatory  ducts.  We  believe  it 
is  impossible  to  remove  the  prostate  according  to  the  Freyer  technique 
without  destroying  the  prostatic  urethra  in  practically  every  instance. 


304 


Technique  of  Operations 


To  Squier  of  New  York  is  due  the  credit  for  having  evolved  a  tech- 
nique of  suprapubic  removal  of  the  prostate  which  theoretically  and 
probably  actually  in  the  majority  of  instances,  allows  of  preservation  of 
the  ejaculatory  ducts.  His  method  isf  ounded  on  careful  studies  of  the 
normal  anatomy  of  the  parts  and  the  changes  to  which  they  are  sub- 
jected as  the  result  of  prostatic  disease.  He  takes  into  careful  con- 
sideration also  the  bearing  of  the  pathogenesis  of  the  disease  on  the 
surgical  problems  of  enucleation. 


•  Fig.  iox. — Intra- urethral  Enucleation  or  the  Prostate. 

Step  5.    (/.  Bentley  Squier,  Surgery,  Gynecology  and  Obstetrics.) 

In  addition  to  less  important  considerations,  Squier  calls  attention 
to  the  backward  displacement  of  the  ejaculatory  ducts  in  hypertrophic 
states  of  the  prostate.  He  likewise  points  out  the  importance  of  the 
fact  that  "  the  urethra  anterior  to  the  colhculus  is  practically  free  from 
the  prostate,  but  posterior  is  quite  intimately  attached." 

Since  the  ejaculatory  ducts  are  out  of  harm's  way  posteriorly,  it 
follows  that  if  the  coUiculus  and  adjacent  urethral  floor  can  be  spared, 
the  terminals  of  these  ducts  will  likewise  be  spared.  This  is  not  a  diffi- 
cult matter  if  the  prostate  is  easily  enucleable  and  if  the  urethral  mucosa 
is  divided  primarily  on  a  plane  posterior  to  the  colliculus;  the  anterior 
portion  being  but  slightly  attached  will  have  little  tendency  to  adhere 
to  the  prostate. 


Squier's  Technique  305 

The  preservation  of  this  part  of  the  urethra  with  the  ejaculatory 
ducts  while  undoubtedly  of  importance  in  the  preservation  of  the  sexual 
function,  is  really  of  minor  importance  in  comparison  with  the  greater 
facility  and  safety  to  the  sphincter  mechanism  of  the  bladder  when  the 
prostate  is  removed  by  the  Squier  method.  We  are  in  the  habit  of  begin- 
ning the  enucleation  by  tearing  through  the  mucous  membrane  cover- 
ing the  most  prominent  portion  of  the  growth  in  the  urethra;  this  almost 
invariably  lies  posterior  to  the  colliculus  but  on  the  side  wall  of  the 
urethra.  In  some  few  instances  it  facilitates  matters  to  begin  the 
enucleation  on  the  floor  of  the  urethra. 

Squier's  Operation. — Squier's  operation  is  described  by  its  origina- 
tor as  follows: 

'We  will  presume  that  all  operative  preliminaries  are  completed 
even  to  the  filling  of  the  bladder,  the  arrangement  of  the  towels,  etc., 
and  the  surgeon  is  ready  to  operate  before  the  anesthetic  is  commenced. 
At  the  moment  of  relaxation,  the  abdominal  incision  is  made  and  the 
bladder  exposed.  The  bladder  is  opened  by  an  incision  large  enough 
to  admit  two  or  three  fingers,  high  up  on  the  fundus  and  close  to  the 
peritoneal  attachment.  This  may  seem  to  be  a  trivial  matter,  yet  it 
has  a  direct  bearing  upon  the  time  required  for  the  healing  of  the 
suprapubic  sinus. 

The  next  step  in  the  operation,  namely,  enucleation  of  the  prostate 
is  necessarily  the  most  important  one. 

''We  have  been  taught  to  remove  the  prostate  from  its  sheath  through 
an  opening  into  the  bladder  mucous  membrane  over  its  most  prominent 
lobe.  Such  an  enucleation  is,  therefore,  started  intravesically.  The 
finger  dissects  forward,  meets  with  the  fibres  of  the  internal  sphincter 
and  external  longitudinal  muscles  where  they  encircle  the  prostate  at 
the  line  of  demarcation  between  intra-  and  extra- vesical  portions,  and  the 
tendency  is  for  the  finger  to  pass  outside  the  muscular  covering  of  the 
prostate  and  thus  remove  the  prostate  as  a  whole  rather  than  the  lobes 
separately.  This  so-called  removal  en  masse  is  characteristic  of 
Freyer's  operation,  in  which  no  effort  is  made  to  save  the  prostatic 
urethra  but  a  removal  of  the  prostate  with  its  encircling  muscle  fibres 
is  aimed  at. 

"The  method  of  enucleation  which  I  prefer  varies  from  this  descrip- 
tion in  that  enucleation  is  begun  extravesically.  It  is  recommended 
because  it  materially  reduces  the  length  of  the  time  of  operation,  on 
account  of  the  rapidity  by  which  the  prostate  can  be  shelled  out,  as  well 

as  by  lessening  the  chance  of  damaging  the  ejaculatory  ducts. 
20 


3o6 


Technique  of  Operations 


The  procedure  is  to  insert  the  finger  into  the  internal  meatus  and 
break  through  the  roof  of  the  prostatic  urethra.  Access  is  at  once 
given  to  the  proper  line  of  cleavage  between  the  lobes,  since  at  this 
point  they  lie  in  close  opposition,  being  separated  only  by  the  capsule. 


Pilcher 
tuTTon 
drciinaqetube  \ 


Fig.  I02. 


Fig.  103. — The  Pilcher  Hemostatic  B.\g. 


"The  enucleation  is  begun  by  pushing  the  finger  upward  and  forward, 
freeing  the  apex  of  the  lobe  from  its  attachment  to  the  urethra  and 
triangular  ligament.     It  is  then  swept  around  the  surface,  and  the  lobe 


Tube  For  inFla'tin9  bag 


through  upcfnjra 


Fig.  104. — Sagittal  Section  of  the  Pilcher  Bag. — {Pilcher,  Cabot's  Urology.) 

is  hooked  back  into  the  bladder  with  its  apex  pointing  upward,  then  a 
little  separation  from  the  bladder  mucous  membrane  completes  its 
removal.  A  similar  procedure  is  repeated  on  the  other  side  and  the 
enucleation  is  complete.  The  moment  the  prostate  has  been  delivered 
the  anesthetic  is  stopped. 


Pilcher's  Technique  307 

*  With  a  httle  care  there  is  no  danger  of  injury  to  the  rectum.  An 
assistant  steadies  the  prostate  through  the  rectum  during  enucleation. 
The  operator  should  not  do  so  as  it  interferes  with  the  immediate 
completion  of  the  operation  because  of  the  necessity  of  resterilization  of 
the  hands  and  changing  of  gloves. 

"Carried  out  in  this  way,  a  suprapubic  prostatectomy  can  be 
accomplished  in  four  or  five  minutes  in  most  cases,  and  the  patient 
need  be  subjected  to  complete  anesthesia  but  two  or  three. 

'Therefore  a  prostate  without  median  outgrowth  may  be  enucleated 
with  practically  no  damage  being  done  to  the  floor  of  the  prostatic 
urethra.  In  cases  where  a  median  outgrowth  exists,  a  part  of  the  floor 
of  the  prostatic  urethra,  namely,  that  portion  which  is  posterior  to  the 
colliculus,  will  come  away  with  the  prostate  on  account  of  its  intimate 
attachment  through  the  prostatic  ducts. 


Fig.  105. — The  Hagner  Hemostatic  Bag. 

"Whether  or  not  this  portion  of  the  urethra  is  removed  is  of  no  great 
moment.  It  is,  however  desirable  to  preserve  the  integrity  of  the 
prostatic  urethra  anterior  to  the  colliculus,  as  here  are  situated  the 
openings  of  the  ejaculatory  ducts.  Fortunately  nature  aids  us  in  so 
doing,  as  the  part  of  this  urethra  is  not  intimately  attached  to  the 
prostate  and,  therefore,  remains. 

"The  operation  just  described  is  not  only  applicable  to  prostates  in 
which  hypertrophy  is  of  the  glandular  type.  It  has  been  the  most 
efficient  means  of  removing  the  small,  hard,  fibrous  prostate  whose 
growth  is  practically  extravesical. " 

Pilcher's  Operation. — Pilcher  recommends  that  the  principles  of 
anoci-association  be  employed  whenever  possible  in  operating  upon 
prostatics.    Local  anesthesia  is  employed  for  preliminary  cystostomy. 

The  night  before  operation  the  patient  is  given  thirty  grains  of 
sodium  bromide  and  this  is  repeated  on  the  morning  of  the  operation. 
Morphine,  grain  3^^  combined  with  atropine,  gr.  3^1 50  is  given  by  hypo- 
dermic one  half  hour  before  the  operation  in  many  cases.  The  local 
application  of  the  principles  of  anoci-association  both  during  the  cystos- 


3o8 


Technique  of  Operations 


tomy  and  later  in  enucleating  the  prostate  as  recommended  by  Lower 
are  followed. 

I.  An  hour  before  the  operation  the  patient  is  given  a  hypodermic 
injection  of  morphine  and  scopolamine,  the  size  of  the  dose  depending 
upon  the  age  of  the  patient. 

II.  Immediately  before  the  operation  the  bladder  is  irrigated 
and  60  to  99  cc.  of  a  five  per  cent,  solution  of  alypin  is  injected 
through  the  catheter.  The  catheter  is  clamped  and  both  catheter  and 
solution  are  allowed  to  remain. 

III.  The  bladder  is  approached  in  the  usual  way  except  that  the 
skin  incision  and  every  division  of  tissue  is  preceded  by  a  thorough 
infiltration  with  novocain  in  3'^oo  solution. 


Sutures . 


Fig.  106. — Hemostatic  Bag  in  Place. 
The  inflating  tube  is  passed  up  through  the  large  drainage  tube.     In  two  or  three  hours 
the  bag  is  allowed  to  deflate  and  the  pressure  is  relaxed.     If  bleeding  recommences,  the 
bag  is  re-inflated  and  pressure  re-established.     The  bag  is  removed  in  twenty-four  hours. — 
{Pilcher,  Cabot's  Urology.) 

IV.  When  the  bladder  is  exposed  it  is  elevated  with  curved  hooks  and 
thoroughly  infiltrated  with  novocain  solution. 

Technique  of  Suprapubic  Cystostomy.  (Pilcher.)— The  bladder  is 
exposed  through  a  mid-line  incision  in  the  usual  manner.  It  is  then  well 
filled  with  sterile  water  through  a  catheter  introduced  by  the  urethra. 

The  finger  is  introduced  into  the  wound  until  the  under  surface  of 
the  symphysis  pubis  is  reached;  then  the  finger  covered  with  gauze  is 


Pilcher's   Technique  309 

slowly  swept  upward,  gradually  lifting  the  tissues  away  from  the 
anterior  surface  of  the  bladder  at  the  same  time  forcing  the  peritoneal 
fold  upward. 

Great  care  must  be  exercised  in  pushing  back  the  peritoneum  for 
it  is  easily  torn. 

The  bladder  having  been  properly  exposed,  retractors  are  intro- 
duced, two  lateral  ones  to  hold  back  the  muscles  and  one  in  the  upper 
angle  of  the  wound  to  hold  back  the  peritoneum. 

Two  retaining  sutures  are  then  introduced  into  the  blader  wall 
about  an  inch  apart  on  either  side  of  the  point  where  the  bladder  is  to 
be  incised.  This  incision  is  made  as  near  to  the  peritoneal  fold  as 
possible.  The  fluid  is  then  allowed  to  flow  out  of  the  bladder  through 
the  urethral  catheter.  Then  the  bladder  is  opened  at  the  point  chosen. 
Digital  exploration  of  the  bladder  cavity  follows.  With  this  completed 
the  button  drainage  tube  is  inserted  and  fixed  in  place  either  by  a  purse- 
string  suture  of  chromic  gut  or  silk,  or  by  tying  the  stay  sutures  around 
the  tube. 

Pilcher  lays  much  emphasis  on  the  importance  of  placing  the  drain- 
age tube  in  the  proper  position.  He  recommends  that  a  second  opening 
be  made  if  the  primary  opening  in  the  bladder  wall  is  found  placed 
too  low.  Closure  of  the  prevesical  space  by  catgut  suture  is  also 
advocated. 

The  wound  is  carefully  closed  by  interrupted  chromic  gut  sutures. 
Interrupted  silk  sutures  are  used  to  close  the  skin  incision  and  the  drain- 
age tube  is  fixed  to  the  skin  by  means  of  an  adhesive  strip.  Wound 
infection  seldom  occurs. 

General  anesthesia  is  rarely  necessary  in  performing  cystostomy, 
according  to  Pilcher;  spinal  anesthesia  is  not  employed. 

The  Convalescent  Period. — Drainage  of  the  bladder  is  begun  as 
soon  as  the  patient  reaches  his  room.  This  may  be  continous  if  there 
has  been  only  a  small  amount  of  residual  urine.  Otherwise  continuous 
drainage  should  be  avoided  for  some  days,  the  bladder  being  emptied 
intermittently.  Irrigation  of  the  bladder  is  not  advised  during  the  first 
three  or  four  days. 

Pilcher  states  that  primary  union  of  the  wound  is  secured  with 
complete  control  of  the  urine;  further  that  the  prevesical  and  perivesical 
spaces  have  been  eliminated  from  the  surgical  problem  and  half  of  the 
operation  of  transvesical  prostatectomy  has  been  completed  without 
the  employment  of  general  anesthesia  and  with  freedom  from  surgical 
shock. 


3IO 


Technique  of  Operations 


Enucleation  of  the  Prostate. — Ether  by  the  drop  method  is  recom- 
mended. The  appUcation  of  the  principles  of  anoci-association  as 
outHned  by  Lower  is  given  in  detail.  This  embodies  the  hypodermic 
infiltration  of  the  prostate  gland  and  its  capsule  with  novocain  solution. 
The  needle  of  the  syringe  containing  the  novocain  solution  is  introduced 
into  the  prostate  through  the  suprapubic  opening 
using  the  finger  as  a  guide. 

If  two  weeks  or  less  have  elapsed  since  the 
cystostomy  operation  it  is  unnecessary  to  use 
instruments  to  enlarge  the  drainage  opem'ng;  the 
silk  sutures  should  not  be  disturbed.  If  the 
sutures  have  cut  through  it  is  sometimes  advan- 
tageous to  re-insert  heavy  silk  sutures  to  prevent 
the  wound  from  tearing  open  during  the  enuclea- 
tion of  the  prostate. 

In  cases  in  which  a  long  time  elapses  between 
the  two  stages  of  the  operation  it  will  probably 
be  necessary  to  enlarge  the  opening.  Pilcher 
speaks  of  this  merely  as  being  of  advantage,  but 
we  have  found  it  absolutely  necessary  in  cases  in 
which  a  button  drainage  tube  has  been  used. 

To  enlarge  the  suprapubic  opening  Pilcher 

suggests  making  three  radiating  incisions  one 

inch  in  length,  extending  on  each  side  of  and 

Fig.  107.-METHOD    OF  downward  from  the  opening.     These  incisions 

Attaching  Catheter  Tube  are  carried  to  the  rectus  sheath.     The  latter  may 

OF  Pilcher  Bag  to  the  Leg  be  incised  when  necessary  and  to  gain  additional 

BY  Means  of  Adhesive         ,1  u      i  r  i.  j*         iU 

T,  T  room   the   subcutaneous   fat  surrounding  the 

Plaster  to  keep  up  Intra-  ^  ° 

vesical  Pressure  on  the  wound  may  be  excised.  The  wound  should  not 
Prostatic  Bed.— (Pilcher,  be  enlarged  upward  on  account  of  the  danger  of 
Cabal's  Urology.)  jjjjyj.y  ^^  ^^^  peritoneum. 

Having  provided  the  necessary  opening  the  enucleation  of  the  prostate 
is  begun.  The  technique  advocated  by  Pilcher  is  in  no  wise  different 
from  the  usual  intra-urethral  enucleation.  For  cases  in  which  median 
lobe  enlargement  is  lacking  but  with  great  enlargement  of  the  lateral 
lobes,  Pilcher  recommends  that  the  enucleation  be  begun  on  the  vesical 
side  after  the  method  of  Freyer. 

Attention  is  called  to  the  importance  of  thoroughly  cleansing  the 
bladder  after  the  removal  of  the  prostate.     This  includes  the  removal 


^dfiwst*^  tape- 


Plicher's  Technique  311 

of  blood  clots,  loose  pieces  of  tissue,  and  of  small  prostatic  calculi 
that  may  have  become  dislodged  during  the  manipulations.  Cleansing 
of  the  bladder  is  best  accomplished  by  wiping  the  debris  away  with 
small  gauze  sponges. 

The  use  of  the  button  catheter  for  suprapubic  drainage  and  the 
method  of  controlling  hemorrhage  after  removal  of  the  prostate  are 
among    the    characteristic  features   of   the   Pilcher   operation.     The 


Fig.  108. — "Enlarging   the   Suprapubic   Opening   after   Cystostomy   when   A 
NEARER  Approach  to  the  Prostate  is  Desired.    The  Wound  is  not  Enlarged  Upward 

BECAUSE    OF    THE    DANGER    OF    OPENING    THE    PERITONEAL    CaVITY." — {Pilcher,    Cabot-'s 

Urology.) 

latter  he  accomplishes  by  means  of  the  bag  hemostat,  an  instrument 
originally  suggested  by  Hagner  but  used  in  an  improved  form  by 
Pilcher. 

To  place  the  bag  in  the  prostatic  bed,  a  silver  prostatic  catheter  is 
passed  through  the  urethra  into  the  bladder  after  the  removal  of  the 
prostate;  its  tip  is  caused  to  emerge  through  the  suprapubic  wound 
and  the  rubber  tube  which  is  attached  to  the  bag  is  fitted  over  the  end 
of  the  catheter  to  which  it  is  firmly  tied;  the  end  of  the  catheter  is  then 
withdrawn  carrying  with  it,  through  the  urethra,  the  rubber  tube. 
The  bag  is  then  inflated  and  the  tube  clamped  off. 


312 


Technique  of  Operations 


The  desired  pressure  on  the  prostatic  bed  may  be  obtained  by- 
exerting  traction  on  the  tube.  The  latter  is  attached  to  the  leg  by  means 
of  adhesive  straps,  thus  completely  controlling  the  degree  of  pressure 
exerted  at  the  vesical  neck. 

Pilcher's  modifications  of  the  Hagner  bag  consist  of  the  addition  of 
a  catheter  arrangement  and  of  a  second  tube  which  is  used  to  inflate 
the  bag.  The  latter  is  brought  out  through  the  suprapubic  wound. 
The  urethral  tube  passes  through  the  bag  and  serves  the  purpose  of  a 
catheter. 


K 

&     ^«^9i 

HBI 

Hi 

"dBH 

^B^i 

■' 

J^^^^m 

^^^^H 

^^m 

^-"j^^^^^^^^^^i 

^^^^^B^   ^\1 

1 

B'                          -^^^^1 

:^m,. 

m^/ 

^a 

^"'             i^-tVtLi-  "Vivwe^^, 

Fig.  ioq.- 


-Tip  of  the  Finger  Introduced  into  Vesical  Portion  of  the  Urethra. 
(Pilcher,   Cabot's   Urology.) 


Removal  of  the  bag  is  easily  accomplished.  If  the  suprapubic 
drainage  tube  is  of  large  diameter  the  deflated  bag  may  be  removed 
through  its  lumen  without  disturbing  the  tube.  The  Hagner  bag  is 
provided  with  a  silk  Hgature  which,  like  the  tube  of  the  Pilcher  bag. 
is  brought  out  through  the  drainage  tube.  The  silk  ligature  serves  for 
the  removal  of  the  bag.  It  is  generally  desirable  to  remove  the  drainage 
tube  and  the  bag  at  the  same  time. 

Pilcher  recommends  that  air  be  used  to  distend  the  bag;  we  have 
employed  hot  water  with  gratifying  results;  it  has  also  been  suggested 
that  metallic  mercury  be  used  for  the  same  purpose. 

In  Pilcher's  opinion  every  case  should  be  drained  after  prostatec- 
tomy; with  this  we  thoroughly  agree.  He  recommends  the  use  of  a 
large  drainage  tube  which  should  not  extend  more  than  a  half  inch 


Pilcher's  Technique  313 

within  the  bladder  cavity.  This  is  in  addition  to  the  drainage  by  the 
catheter  per  urethram. 

After-Treatment. — A  considerable  degree  of  pressure  is  exerted 
on  the  prostatic  bed  for  the  first  hour  after  prostatectomy. 

The  adhesive  strips  attached  to  the  leg  are  then  cut  and  the  bag  is 
deflated  but  is  left  in  situ  lest  secondary  bleeding  should  occur.     It  is 


Fig.  no. — Separation   of   the   Sphincter   Muscle   from  the   Prostate. — {Pitcher, 

Cabot's  Urotogy.) 


removed  in  from  twenty-four  to  forty-eight  hours.  Should  an  excessive 
amount  of  blood  appear  in  the  drainage  fluid  the  bag  is  again  inflated 
and  traction  exerted  on  the  urethral  tube,  as  before. 

In  the  absence  of  complications,  the  patient  is  allowed  to  sit  up  in  a 
chair  the  day  following  operation.  If  the  bag  gives  rise  to  discomfort 
it  may  be  removed  together  with  the  suprapubic  drainage  tube,  at  the 
end  of  twenty-four  hours;  otherwise  they  are  not  disturbed  until  the 
end  of  the  forty-eight  hour  period. 

To  remove  the  bag  it  is  merely  necessary  to  deflate  it — to  cleanse 
the  distal  end  of  the  urethral  tube  and  apply  to  it  a  sterile  lubricant, 
and  to  cut  the  suture  holding  the  suprapubic  drainage  tube;  the  latter, 
together  with  the  bag  may  now  be  withdrawn  through  the  suprapubic 
wound. 


314  Technique  of  Operations 

The  patient  will  not  sufifer  any  pain  if  the  bag  is  withdrawn  slowly 
and  with  gentleness. 

The  deflated  bag  may  be  removed  without  disturbing  the  supra- 
pubic drain  if  the  latter  is  wide  enough  to  permit  its  passage. 


Fig.  III. — "Atter  Freeing  the  Internal  Sphincter,   the   Finger  is    forecd 

THROUGH   the   PROSTATIC   UrETHRA   TO   ITS    UTMOST  DiSTAL   POINT  AND  HeRE  THE  ReAL 

Enucleation  of  the  Gland  is  Begun.  With  one  Finger  in  the  Rectum,  and  One 
Finger  in  the  Bladder  the  Gland  can  be  Almost  Entirely  Controlled.  If  Enuclea- 
tion with  One  Finger  is  difficult,  it  will  be  found  that  bv  using  the  First  and 
Second  Fingers  Enucleation  is  Facilitated." — {Pilcher,  Cabot's  Urology.) 

We  prefer  not  to  remove  the  drainage  tube,  but  Pilcher  recommends 
the  early  substitution  for  it  of  a  button-catheter  introduced  into  the 
bladder  immediately  after  the  drainage  tube  is  removed,  using  as  a 
guide  for  the  purpose,  a  long  narrow  retractor. 

The  enlarged  end  of  the  button-catheter  is  grasped  with  a  pair  of 
dressing  forceps  which  are  made  to  follow  along  the  groove  of  the  narrow 
retractor  into  the  cavity  of  the  bladder.  The  catheter  is  then  released 
and  the  forceps  and  retractor  are  withdrawn.     According  to  Pilcher, 


Judd's  Technique 


315 


the  bladder  wall  contracts  immediately  and  holds  the  catheter  in  place. 
It  serves  he  says  to  completely  drain  the  urine  away  in  most  cases  so 
that  the  patient  is  kept  dry.  The  button  catheter  is  not  removed  until 
the  patient  has  begun  to  pass  the  urine  per  urethram.  If  success 
attends  this  first  effort  the  patient  will  have  little  trouble  in  regaining 
the  normal  function  of  his  bladder. 


Fig.  112. — Enucleated  Prostate   ^.'urned  out  into  the  Bladder. — {Pilcher,  Caboi's 

Urology.) 


Most  of  the  patients  will  not  need  the  drainage  tube  after  the  tenth 
or  eleventh  day,  and  when  it  is  removed  there  is  very  Httle  leakage  of 
urine  through  the  sinus  which  quickly  closes. 

Judd's  Operation. — This  differs  in  some  respects  from  the  operation 
of  suprapubic  prostatectomy  as  it  is  ordinarily  performed,  especially 
in  the  manner  of  controlling  hemorrhage.  Judd  also  advocates  pri- 
mary closure  of  the  suprapubic  wound  in  selected  cases,  depending 
entirely  upon  a  catheter  per  prethram  for  drainage. 

A  wide  exposure  of  the  prostatic  area  is  provided  through  a  supra- 
pubic opening  of  generous  dimensions.  Self-retaining  retractors  aid 
in  the  exposure  of  the  operative  field. 

The  prostatic  mass  is  grasped  with  forceps,  if  this  is  practicable, 


3i6  Technique  of  Operations 

and  is  lifted  up  and  steadied  while  the  enucleation  is  proceeded  with. 
The  latter  is  begun  much  after  the  method  of  Freyer,  the  gland  being 
separated  first  from  the  sphincter  muscle  and  bladder  walls. 

After  the  prostate  has  been  freed  and  removed  from  the  bladder, 
the  cavity  whence  it  came  is  carefully  inspected.  Spurting  vessels  are 
clamped  and  tied  with  catgut.  The  torn  edges  of  the  vesical  mucous 
membrane  are  caught  with  clamps  and  a  few  sutures  of  chromic  catgut 
are  inserted.  These  are  placed  so  as  to  include  the  bladder  wall  and  the 
adjacent  sides  of  the  prostatic  bed;  when  they  are  tied  all  bleeding 
from  the  vesical  mucosa  is  controlled. 

The  area  is  again  examined  carefully  and  if  all  bleeding  is  controlled 
a  catheter  is  passed  per  urethram  for  drainage  and  the  suprapubic 
wound  is  tightly  closed. 

Perineal  Prostatectomy. — So  many  variations  and  modifications 
of  this  operation  have  been  suggested  that  a  minute  description  of  each 
in  a  work  of  this  kind  would  be  impracticable.  All  of  the  methods 
employed,  however,  may  be  classed  in  either  one  of  two  categories — 
those  in  which  the  gland  is  removed  from  within  the  urethra  through  a 
straight  perineal  incision,  and  the  extra-urethral  perineal  prostatectomy, 
as  seen  in  the  technique  of  the  French  School  developed  by  Proust  and 
popularized,  in  a  modified  form,  by  Young  in  this  country. 

Perineal  removal  of  the  prostate  or  of  parts  of  it  through  a  small 
perineal  incision  is  rarely  if  ever  practised  at  the  present  time,  although 
this  was  the  perineal  operation  advocated  by  many  American  surgeons 
before  the  elaborate  dissections  of  the  perineum  characteristic  of  the 
Proust  and  Young  operations  came  into  popular  favor.  Likewise  with 
the  perfection  of  the  latter,  the  intra-urethral  perineal  operations  have 
gradually  fallen  into  disuse. 

Intra-urethral  Perineal  Prostatectomy. — The  credit  for  the  develop- 
ment of  the  intra-urethral  method  of  perineal  prostatectomy  is  due  to 
Goodfellow  who,  in  collaboration  with  Wishard,  introduced  it  to  the 
profession  in  1891. 

The  first  of  the  modern  operations  of  extra-urethral  perineal 
prostatectomy — that  of  Zuckerkandl — antedated  this  by  several  years. 
It  should  not  be  forgotten  that  Goodfellow's  operation  antedated  the 
transvesical  or  suprapubic  operation  of  Fuller  and  Freyer. 

Dr.  Goodfellow's  own  description  of  his  operation  is  as  follows: 
''The  usual  pre-operative  procedures  are  carried  out.  .  .  .  With 
the  patient  in  the  ordinary  lithotomy  position,  the  legs  held  by  assist- 
ants, the  bladder  being  empty  or  full  as  the  case  may  be,  a  lithotomy 


Perineal  Prostatectomys 


317 


staff  is  introduced,  the  legs  then  elevated  somewhat,  a  median  incision 
from  the  base  of  the  scrotum  to  the  margin  of  the  anus  is  made,  and 
carried  to  the  membranous  urethra,  which  is  entered  with  a  straight 
lithotomy  knife  and  the  opening  extended  into  the  bladder.  The  finger 
is  then  introduced  into  the  bladder,  the  staff  remov^ed,  and  the  moderate 
flexion  of  the  legs  and  thighs  on  the  abdomen  and  the  thorax  increased 
to  as  great  an  extent  as  possible;  then  with  the  opposing  hand  over  the 
hypogastrium  the  bladder  is  depressed,  and  the  enucleation,  beginning 


Fig.  113. — The  dePezzer  Catheter  in  Place  at  High  Point  of  Bladder. — {Pilcher, 

Cabot's    Urology.) 

at  the  beak  of  the  prostate  below  and  working  upward  next  to  the 
bladder,  or  from  above  on  either  side  downward,  is  carried  on,  the  time 
consumed  for  complete  enucleation  rarely  being  over  five  or  ten  minutes, 
the  resulting  haemorrhage  being  virtually  nothing.  The  gland  may  be 
removed  entire  or  lobe  by  lobe ....  What  becomes  of  the  prostatic 
urethra?  has  been  asked.  The  answer  is  that  part  or  all  is  removed 
with  the  gland,  an  incident  that  in  no  manner  seems  to  affect  the  restora- 
tion or  the  continuity  of  the  urethra,  nor  the  power  of  the  bladder  to 
regain  and  control  its  functions;  nor  is  stricture  or  occlusion  caused. 
The  seminal  ducts  are  not  ligated,  for  this  seems  to  me  an  irrational 
refinement,  especially  as  many  of  my  patients  have  (so  they  say)  to  a 
greater  or  less  extent  regained  sexual  vigor. " 

"The  points  to  be  expressly  emphasized  are  the  position  and  the 


3i8 


Technique  of  Operations 


incision  into  the  bladder.   ...     I  do  not  find  it  necessary  now  to 
use  the  knife  to  enter  the  urethra  and  bladder.     After  cutting  to  the 


Fig.  114. — Proust's  Inverted  Perineal  Position  for  Perineal  Prostatectomy. 

urethra  I  am  able  with  the  finger  to  open  it  and  get  into  the  bladder  by 
a  boring  movement.  -  Then  not  having  a  cut  through  the  commissure, 
I  enucleate  from  above  instead  of  from  below  as  formerly." 


Perineal  Prostatectomy  319 

American  surgeons,  among  whom  may  be  mentioned  Alexander, 
Syms,  Ferguson,  Murphy,  Watson,  Cabot,  Guiteras,  Cunningham 
and  Bryson,  were  enthusiastic  in  their  support  of  the  Goodfellow 
operation.     Certain  modifications  and  improvements  in  technique  were 


Fig.  115. — Perineal  Prostatectomy. — {Proust.) 
The  transverse  perineal  incision. 

soon  suggested  and  various  instruments  were  designed  to  facilitate  the 
removal  of  the  gland.  Difficulties  in  bringing  the  prostate  within  the 
reach  of  the  finger  were  encountered  and  the  pressure  of  an  assistant's 
hand  over  the  bladder,  as  advised  by  Goodfellow  for  the  pui^se,  was 


320  Technique  of  Operations 

found  insufficient.  This  led  Nicoll  and  others  to  open  the  bladder 
above  the  pubis,  introduce  the  hand  or  fingers  into  the  bladder  cavity 
and  make  direct  counter  pressure  on  the  prostate  during  the  enucleation. 

To  obviate  the  necessity  for  opening  the  bladder,  Bryson,  Guiteras, 
and  others  merely  opened  into  the  space  of  Retzius  and,  with  the  hand 
in  this  extravesical  position,  made  the  desired  counter-pressure  on  the 
prostate. 

Partly  owing  to  the  unsatisfactory  results  with  the  aforementioned 
methods,  and  doubtless  also  because  of  the  introduction  of  practical 
prostatic  tractors,  the  suprapubic  incision  was  discarded. 

Among  the  tractors  that  met  with  more  or  less  favor  may  be  men- 
tioned those  of  Delbet,  Albarran,  dePezzer,  Syms,  Ferguson,  and 
Guiteras.  Various  other  instruments  were  introduced  whose  purpose 
it  was  to  pull  down  the  prostate;  prominent  among  the  latter  were 
Murphy's  hooks. 

The  development  of  the  intra-urethral  perineal  operation  had  made 
considerable  progress  and  many  operators  had  expressed  great,  if  not 
complete,  satisfaction  with  the  results  attained,  when  Proust  described 
his  method  of  extra-urethral  removal  of  the  prostate  through  the 
perineum. 

The  Proust  technique  embodies  the  basic  principles  of  perineal  prosta- 
tectomy as  it  is  now  performed.  What  popular  favor  the  operation  now 
enjoys  in  this  country,  however,  is  due  to  the  work  of  Young  who  modi- 
fied the  Proust  technique  and  brought  it  to  a  high  state  of  perfection. 

With  the  introduction  of  extra-urethral  prostatectomy  the  opera- 
tions of  Goodfellow  and  his  followers  fell  more  and  more  into  disuse. 
Among  the  more  prominent  urologists  who  clung  to  the  intra-urethral 
technique  may  be  mentioned  Watson  whose  method  differed  but  slightly 
from  that  of  Goodfellow. 

Within  recent  years  the  intra-urethral  operation  has  been  practi- 
cally abandoned,  although  A.  J.  Ochsner  still  advocates  it  but  in  a 
modified  form.  He  employs  a  lateral  perineal  lithotomy  incision 
through  which  the  membranous  and  prostatic  urethras  are  cut  poste- 
riorly. Having  thus  opened  the  urethra,  the  finger  is  introduced  into 
the  bladder  and  the  prostate  is  enucleated  in  exacuy  the  same  manner 
as  with  Freyer's  technique.  The  freed  prostate  is  then  grasped  with 
Young's  forceps  and  removed.  The  left  index  finger  is  then  introduced 
into  the  bladder  and  under  its  guidance  the  edges  of  the  prostatic  capsule 
are  caught  with  fine  tooth  forceps  and  drawn  downward.  Two  rubber 
drainage  tubes,  one  within  the  other,  are  next  introduced;  the  longer 


Perineal  Prostatectomy  321 

inner  one,  whose  diameter  is  one  cm.  drains  the  bladder  cavity,  the 
shorter  outer  tube,  which  fits  snugly  over  the  other,  reaches  only  to  the 
prostatic  cavity.  Ferguson  retractors  are  then  applied  and  gauze  is 
packed  into  capsules  around  the  drainage  tubes.  The  outer  tube  is 
fixed  to  the  margins  of  the  incision  by  means  of  a  silk  worm  gut  suture, 
and  the  wound  is  closed  in  the  usual  manner. 

In  the  event  that  a  hard  prostate  is  encountered,  Ochsner  advises 
its  removal  by  means  of  Ferguson  rongeur  forceps. 

Extra-urethral  Perineal  Prostatectomy. — This  term  is  used  to 
signify  an  enucleation  of  the  prostate  by  a  perineal  dissection  is 
carried  out  either  entirely,  or  in  part,  outside  of  the  urethra.  The  prin- 
ciples upon  which  the  operation  is  founded  were  first  outlined  and  given 
to  the  profession  by  Proust  and  Albarran  of  the  French  school  in  about 
1900. 

At  this  same  time  Young,  of  Johns  Hopkins  University,  was  engaged 
in  the  development  of  a  technique  for  perineal  prostatectomy,  the  details 
of  which  were  described  in  the  Journal  of  the  American  Medical 
Association,  October  24,  1903. 

Young  states  that  his  operation  "was  developed  quite  independ- 
ently and  without  knowledge  of  the  work  of  the  French  school  to  which 
however  it  bore  resemblance,  but  only  superficially." 

If  one  reads  very  carefully  the  original  descriptions  of  the  Proust 
and  Young  operations  he  is  impressed  with  the  parallelism  of  the  two 
procedures  up  to  a  certain  point.  True  the  skin  incisions  differ,  and 
in  certain  instances,  Proust  advised  lateral  incision  of  the  levator  ani 
muscles,  but  until  the  actual  beginning  of  the  enucleation,  the  two 
operations  are  strikingly  similiar.  In  each  the  urethra  is  exposed 
behind  the  triangular  ligament;  the  dePezzer  tractor  which  Proust 
employed  to  depress  the  prostate  is  very  similiar  to  the  Young  tractor, 
but  the  methods  of  employing  the  two  instruments  were  quite  dissimilar. 

Having  inserted  the  dePezzer  tractor  and  spread  its  blades  over 
the  vesical  surface  of  the  prostate,  the  instrument  was  used  by  Proust 
merely  to  steady  the  organ  while  freeing  it  from  all  of  its  attachments 
save    where   it  was  adherent  to  the  urethra  and  ejaculatory  ducts. 

The  enucleation  was  begun  through  an  incision  made  in  the  sheath 
of  the  prostate  where  it  covers  the  rectal  surface  of  the  gland.  This 
incision  was  made  parallel  with  the  urethra  but  apparently  did  not,  as 
do  the  incisions  recommended  by  Young,  go  deeply  into  the  compressed 
prostatic  tissue  (false  capsule)  which  lies  superficial  to  the  hypertrophied 
lobes. 

21 


322  Technique  of  Operations 

Having  made  an  incision  in  the  sheath,  Proust  advised  that  the 
finger  be  introduced  into  the  space  thus  created  and  that  the  gland  be 
freed  by  careful  dissection  on  all  surfaces,  with  the  exceptions  just  noted. 
The  retractor  was  then  removed  and  the  floor  of  the  prostatic  urethra 
incised.  The  finger  was  then  introduced  into  the  urethra  and  the 
remaining  attachments  of  the  prostate  freed,  care  being  taken  to  preserve 
the  major  portion  of  the  urethral  walls.  The  ejaculatory  ducts  were 
ligated  routinely. 

Evidently  from  this  description,  the  Proust  method  of  enucleation 
differed  widely  from  that  described  by  Young  whose  operation  provides 
for  separate  removal  of  the  lateral  lobes  through  incisions  placed 
lateral  to,  but  parallel  with  the  urethra. 

It  becomes  evident  from  Proust's  description  of  his  operation  that  he 
failed  to  comprehend  the  essential  points  in  the  gross  pathology  of 
prostatic  hypertrophy,  or  else  he  would  not  have  commenced  the  enuclea- 
tion between  the  sheath  and  the  gland.  Had  he  recognized  the  exist- 
ence of  a  false  capsule,  as  did  Young,  and  deepened  the  incision  on  the 
posterior  surface  of  the  prostate  so  as  to  reach  the  line  of  cleavage  be- 
tween the  hypertrophic  portion  and  the  false  capsule,  the  entire  enuclea- 
tion could  have  been  completed  without  incision  into  the  floor  of  the 
urethra.  Undoubtedly  the  prostatectomy  of  Proust  insured  a  thorough 
and  complete  removal  of  the  gland,  but  the  virtues  that  this  might  seem 
to  hold  are  wanting  since  it  is  not  only  unnecessary  but  materially 
adds  to  the  gravity  of  the  operation.  Proust's  operation  is  no  longer 
advocated  even  by  the  French  school  of  urologists. 

The  Young  operation  is  superior  to  any  other  perineal  prostatectomy 
thus  far  proposed;  rarely  do  we  follow  the  perineal  route  in  operation 
on  the  prostate,  but  when  circumstances  indicate  this  as  the  preferable 
procedure  the  method  of  Young  is  chosen. 

Perineal  Prostatectomy — ^Technique  of  Young. — The  operation  of 
Young  is  an  extra-urethral  operation  in  the  true  sense  of  the  word, 
since  the  enucleation  of  the  prostate  is  done  entirely  from  the  outside 
and  not  in  part  from  the  urethral  side,  as  recommended  by  Proust. 

The  method  is  called  "conservative"  perineal  prostatectomy, 
its  special  feature  being  the  preservation  of  the  connection  between  the 
ejaculatory  ducts  and  the  urethra. 

The  position  he  advises  may  be  characterized  as  the  "exaggerated 
lithotomy  position,"  the  patient's  thighs  being  fully  flexed  on  the 
abdomen,  so  as  to  bring  the  perineum  more  nearly  parallel  with  the  floor. 

Before  elevating  the  thighs,  a  sound,  which  is  to  be  used   subse- 


Young's  Perineal  Prostatectomy 


323 


quently  as  a  guide  for  the  urethrotomy,  is  inserted  into  the  posterior 
urethra. 

The  incision  is  shaped  like  an  inverted  V,  the  apex  of  which  is  placed 
over  the  posterior  position  of  the  bulb  about  five  cm.  distant  from 
the  anus.     The  arms  of  the  incision  are  made  parallel  with  the  ischio- 


FiG.  116. — Young's  Sound  Guide. 


Fig.  117. — Young's  Dissector,  Sharp  and  Blunt. 


^^^tTm^^^^^-^ 


Fig.  118. — Young's  Boomerang  Needle  Holder. 


Fig.  119. — Young's  Bifid  Retractor. 


pubic  rami,  each  one  being  about  five  cm.  in  length.  The  scalpel  is 
carried  to  the  level  of  the  deep  fascia  after  which  the  necessary  exposure 
is  obtained  largely  by  blunt  dissection. 

The  index  finger  is  pushed  through  the  soft  cellular  tissue  to  either 
side  of  the  central  tendon  of  the  perineum,  thus  opening  up  a  space 
which  is  bounded  in  front  by  the  transverse  muscles  of  the  perineum  and 
laterally  by  the  levator  ani  muscles.  With  the  displacement  of  these 
muscles  a  large  cavity  is  exposed  to  either  side  of  the  central  tendon 
into  which  the  blades  of  a  bifid  retractor  are  placed. 

The  purpose  of  the  retractor  is  to  enable  the  operator  to  put  the 
central  tendon  and  associated  muscles  on  the  stretch  in  order  that  they 


324  Technique  of  Operations 

may  be  severed  close  to  the  bulb  without  danger  of  injury  to  the  latter 
structure.  At  this  stage  of  the  dissection  there  is  only  slight  danger  of 
wounding  the  rectum.  But  having  freed  the  musculo-tendonous 
structures  from  the  bulb,  the  rectum  is  in  great  danger  of  injury  if  the 
knife  or  scissors  are  used  recklessly,  since  it  not  infrequently  is  drawn 
forward  in  front  of  the  membranous  urethra  by  the  recto-urethralis 
muscle. 

This  muscle  lies  between  the  levator  ani  muscles  and  covers,  and  is 
attached  to  the  membranous  urethra  anteriorly,  and  to  the  anterior 
wall  of  the  rectum  posteriorly. 

To  properly  expose  the  recto-urethralis  muscle  and  thus  avoid 
injuring  the  rectum  when  the  muscle  is  divided,  it  is  well  to  heed  the 
advice  of  Young  and  pull  the  bulb  forward  with  a  suitable  retractor 
before  any  attempt  is  made  to  divide  the  muscle.  Indeed,  the  secrets 
of  success  in  this  operation  are  adequate  skill  in  dissection  to  expose, 
and  the  anatomical  knowledge  necessary  to  recognize  each  individual 
structure.  It  is  never  permissible  to  incise  a  tissue  until  its  identity 
and  limitations  have  been  determined. 

The  greatest  danger  in  the  operation, — injury  to  the  rectum 
— arises  during  the  division  of  the  recto-urethralis  muscle;  there  is, 
however,  little  likelihood  of  this  occurring  if  the  central  tendon  has  been 
properly  divided,  the  bulb  displaced  forward,  and  the  division  of  the 
muscle  made  close  to  the  urethra. 

Having  divided  the  recto-urethralis  muscle,  the  rectum  may  be 
pushed  backward  thus  exposing  a  space  in  which  all  of  the  subsequent 
steps  of  the  operation  will  be  carried  out.  This  space  is  bounded  pos- 
teriorly by  the  rectum,  anteriorly  by  the  prostate,  the  membranous 
urethra  and  deep  perineal  interspace  within  the  confines  of  the  trian- 
gular ligament,  and  laterally  by  the  levator  ani  muscles. 

By  pulling  the  bulb  forward  a  good  view  of  the  urethra  between 
the  triangular  ligament  and  apex  of  the  prostate  is  obtained.  Posterior 
and  lateral  retractors  aid  in  providing  the  necessar}^  free  exposure  of 
the  parts. 

The  next  step  in  the  operation  is  to  incise  the  urethra  in  its  long 
axis  over  the  sound,  at  a  point  just  distal  to  the  apex  of  the  prostate; 
this,  which  is  in  reality  a  part  of  the  membranous  urethra,  comes  into 
view  only  when  the  triangular  ligament  and  its  contained  structures  are 
displaced  forward  along  with  the  bulb  of  the  urethra. 

The  urethral  incision  should  be  no  longer  than  is  necessary  to  admit 
of  the  introduction  of  Young's  prostatic  tractor.     Before  removing 


Young's  Perineal  Prostatectomy  325 

the  sound  from  the  urethra  the  edges  of  the  urethral  incision  are  caught 
up  on  either  side  with  clamps  or  ligature,  care  being  taken  to  include 
the  mucous  membrane.  Failure  to  make  a  clean  cut  and  especially  to 
include  the  urethral  mucosa  in  the  clamps  may  be  followed  by  the  great- 
est difficulty  in  attempting  to  insert  the  tractor. 

Having  opened  the  urethra,  and  with  the  clamps  properly  and  securely 
placed  on  the  margins  of  the  incision,   the  sound  may  be  removed. 

To  facilitate  the  introduction  of  the  tractor,  the  prostatic  urethra 
is  dilated  with  sounds  introduced  through  the  opening  in  the  urethra. 
The  insertion  of  the  tractor  is  not  always  easy,  especially  in  cases  in  which 
obstructing  nodes  of  prostatic  tissue  have  deformed  the  urethral  lumen, 
but  by  rotating  the  instrument,  turning  its  beak  from  side  to  side,  etc., 
it  can  generally  be  made  to  enter  the  bladder  cavity. 

After  assuring  himself  that  the  beak  of  the  instrument  has  entered 
the  bladder,  the  operator  separates  the  blades  and  fixes  them  in  position, 
a  set  screw  being  provided  for  the  purpose. 

The  prostate  is  now  drawn  downward  and  forward  by  pulling  on  the 
tractor  and  turning  it  upward  and  backward  over  the  symphysis 
pubis,  the  anterior  retractor  having  been  removed  in  the  meantime. 
The  prostate  is,  as  it  were,  pried  out  of  its  normal  position,  the  tractor 
acting  as  a  lever  with  the  pubic  symphysis  playing  the  role  of  a  fulcrum. 
This  description  is  figurative  rather  than  real,  since  great  traction 
is  usually  unnecessary  to  bring  the  prostate  to  the  proper  level,  but  it 
serves  at  least  to  illustrate  the  principles  involved. 

But  one  structure  alone  remains  to  be  divided  before  full  exposure 
of  the  prostate  is  obtained;  this  is  the  posterior  layer  of  the  fascia  of 
Denonvillier  which  covers  the  rectal  surface  of  the  gland.  A  transverse 
incision  is  made  through  this  fascial  layer  near  to  the  apex  of  the  prostate 
and  the  finger  is  then  made  to  seek,  and  easily  finds  a  space  between  it 
and  the  latter  organ — ''I'espace  decollable  retroprostatique."  The 
anterior  layer  of  Denonvilliers'  fascia,  which  is  inseparably  bound  to  the 
prostatic  sheath,  is  thus  brought  into  view.  By  enlarging  this  incision 
the  rectum  is  freely  mobilized  and  not  only  the  prostate  but  the  seminal 
vesicles  as  well,  are  brought  into  view.  The  rectum  may  now  be  held 
with  a  retractor  in  such  manner  that  it  will  not  intrude  itself  upon  the 
operative  field. 

This  completes  the  preliminary  stages  of  the  operation,  the  most 
important  part  of  which,  namely,  the  enucleation  of  the  gland,  follows. 

If  the  dissection  up  to  this  point  has  been  done  properly  and  with 
the  various  retractors  held  properly  in  position  by  assistants,  an  excel- 


326  Technique  of  Operations^ 

lent  exposure  of  the  posterior,  or  rectal  surface  of  the  prostate  is 


Fig.  120. — Young's  Spoon  Tractor. 


Fig.  1 2  f . — Young's  Lateral  Retractor 


Fig.  122. — Young's  Retractor   Bulb 


Fig.  123. — ^Young's  Prostatic  Tractor. 

obtained;  indeed,  in  many  instances,  the  gland  may  be  brought,  almost  if 
not  actually,  to  the  surface  of  the  perineum. 

The  capsule  is  incised  on  either  side  of  the  median  line.  These 
incisions  are  made  about  1.5  cm.  in  depth  and  extend  almost  the  entire 
length  of  the  posterior  surface  of  the  prostate.  They  diverge  slightly 
from  before,  backwards,  being  about  1.8  cm.  distant  behind  and  1.5 
cm.  distant  in  front. 


Young's  Perineal  Prostatectomy  327 

Young  explains  that  the  advantage  of  deep  incisions  lies  in  the  ease 
with  which  the  finger  can  be  made  to  find  the  line  of  separation  between 
the  hypertrophied  lobes  and  the  urethral  wall.  Deep  incisions  likewise 
permit  the  operator  easily  to  find  the  line  of  cleavage  between  the  cap- 
sule and  the  posterior  and  lateral  surfaces  of  the  hypertrophied  lobes. 
In  fact,  Young  advises  that  the  enucleation  be  begun  on  the  posterior 
surface  and  that  this  surface  and  the  lateral  surface  be  separated  from 
the  capsule  by  means  of  a  blunt  dissector  before  an  attempt  is  made  to 
free  the  remaining  surfaces. 

It  is  well,  in  this  connection  to  recall,  that  the  posterior  lobe  tubules 
of  the  prostate  rarely  if  ever  share  in  the  hypertrophic  process,  but 
become  compressed  as  the  result  of  the  growth  of  the  hypertrophic  lateral 
lobes.  Thus  they  come  to  contribute  to  the  formation  of  the  false 
capsule,  hence  the  deep  incision  necessary  to  reach  the  line  of  cleavage. 

Having  freed  the- posterior  and  lateral  surfaces  of  the  prostate  on 
either  side,  the  urethral  surface  is  freed  in  a  similiar  manner,  care  being 
taken  to  inflict  the  minimal  amount  of  injury  to  the  urethral  walls. 

Firm  adhesions  will  be  foimd  binding  the  apex  of  each  lateral  lobe 
to  the  capsule  and  it  is  necessary  to  use  the  scissors  at  this  point.  After 
freeing  the  apices  of  the  lateral  lobes,  the  enucleation  is  completed  by 
carrying  the  finger  along  the  anterior  surface  of  each  lobe  until  the 
bladder  surface  is  reached,  which  alone  remains  to  be  separated.  The 
enucleation  is  facihtated  by  exerting  traction  on  the  lobes,  a  special 
forceps  being  provided  for  this  purpose. 

As  a  rule,  the  hypertrophied  lateral  lobes  can  be  removed  without 
tearing  into  either  the  urethral  or  the  vesical  mucosa,  but  should  this 
occur,  it  is  not  of  great  importance  and  it  is  not  necessary  to  make  any 
attempt  to  repair  the  damage. 

No  one  method  of  enucleation  is  applicable  to  all  cases,  and  instead 
of  the  orderly  sequence  of  events  just  described,  the  removal  of  an 
adherent  fibrous  prostate  oftentimes  proves  a  difficult  task  and  one  in 
which  morcellement  must  be  practised,  removing  the  organ  piece- 
meal. In  fact,  we  frequently  fall  far  short  of  the  ideal  in  these  exceed- 
ingly difficult  cases  in  which  it  becomes  necessary  at  times,  not  only  to 
destroy  the  ejaculatory  ducts  but  a  portion  of  the  urethra  as  well, 
in  our  efforts  to  remove  the  obstructing  organ. 

In  the  ordinary  case  of  benign  prostatic  hypertrophy,  however,  the 
procedure  just  described  sufficies  completely  to  remove  the  obstruction 
at  the  vesical  outlet  without  endangering  the  integrity  of  the  ejacula- 
tory ducts. 


328  Technique  of  Operations 

The  presence  of  isolated  median  lobe  enlargements  or  median  bar 
formations  at  the  posterior  lip  of  the  vesical  outlet  necessitates  addi- 
tional dissection.  Their  removal  is  best  accomplished  by  delivering 
them  into  one  or  other  of  the  cavities  left  after  removal  of  the  lateral 
lobes.  Whether  the  remaining  obstruction  is  in  the  nature  of  a  lobe 
or  median  bar  its  relation  to  the  ejaculatory  ducts  is  exactly  the  same; 
both  lie  beneath  the  floor  of  the  urethra  primarily,  and  in  front  of  the 
ducts. 

The  enlarged  median  lobe  can  be  delivered  more  easily  into  one  of 
the  lateral  cavities,  the  delivery  being  accomplished  by  means  of  the 
tractor  blades  or  with  the  finger  pressing  on  the  lobe  through  the  walls 
of  the  cavity  on  the  opposite  side. 

Young  advises  that  the  tractor  be  removed  from  the  bladder  before 
attempting  the  removal  of  a  transverse  or  median  bar.  The  latter 
is  picked  up  with  a  sharp  hook  through  one  of  the  lateral  cavities;  it  is 
then  dissected  free  from  the  ejaculatory  ducts  behind  and  the  urethra 
in  front,  either  by  blunt  dissection  or  with  the  aid  of  the  scissors.  After 
the  removal  of  the  bar,  the  finger  can  be  passed  through  the  space 
whence  it  came,  from  one  lateral  cavity  to  the  other. 

Rarely  is  the  urethral  wall  intact  at  the  conclusion  of  a  perineal 
prostatectomy,  and  advantage  may  be  taken  of  the  rents  in  the  mucous 
membrane  for  digital  exploration  of  the  interior  of  the  bladder. 

Most  important  in  this  connection  is  the  condition  of  the  vesical 
outlet;  are  there  any  remaining  lobules  of  prostatic  tissue — is  the 
sphincteric  area  infiltrated  with  a  constricting  ring  of  fibrous  tissue 
which  demands  dilatation — does  the  bladder  contain  calculi? 

These  are  the  important  factors  which  must  be  searched  for  and  if 
found,  corrected,  before  the  operation  can  be  said  to  be  completed. 

Calculi  may  be  removed  through  an  incision  on  the  lateral  wall  of 
the  urethra.  This  incision  may  be  carried  through  the  sphincteric 
area  if  the  calculi  are  too  large  to  be  delivered  through  the  vesical  outlet. 
These  tissues  must  be  brought  together  with  sutures  after  the  removal  of 
the  stones.  We  have  never  had  occasion  to  remove  large  stones  from 
the  bladder  during  the  course  of  a  perineal  prostatectomy  although 
Young  states  that  a  stone  five  cm.  in  diameter  can  be  removed  in  the 
manner  just  described. 

In  our  judgment  the  presence  of  stones,  especially  large  ones, 
compHcating  hypertrophy  of  the  prostate,  is  a  very  definite  indica- 
tion for  the  suprapubic  operation;  we  should  certainly  hesitate 
before  enlarging  an    urethral  incision   through  the   sphincteric  area 


After-Treatment  329 

into  the  bladder,  for  the  purpose  of  removing  a  large  stone,  on  ac- 
count of  the  danger  of  permanent  incontinence  of  urine  following  this 
procedure. 

Wide  dilatation  of  the  internal  vesical  sphincter,  while  not  attended 
with  the  same  danger  of  incontinence  as  division  of  the  muscle,  is 
nevertheless,  dangerous.  There  can  be,  it  seems  to  us,  no  question  of 
the  superiority  of  the  suprapubic  operation  when  stones  are  a  complicat- 
ing factor. 

It  now  remains  properly  to  drain  and  to  close  the  wound.  For  the 
former  purpose  a  catheter  of  large  calibre  is  used.  Through  this  the 
bladder  is  thoroughly  cleansed  of  blood  clots  and  debris  by  irrigations 
of  hot  saline  solution. 

The  lateral  cavities  are  packed  with  strips  of  gauze,  the  ends  of 
which  are  brought  out  along  with  the  drainage  tube. 

Young  advises  as  a  final  step  in  the  operation,  careful  digital  explora- 
tion of  the  rectum  in  search  for  injuries  which,  if  present,  must  be 
sutured. 

The  levator  ani  muscles  are  drawn  together  in  front  of  the  rectum 
by  a  single  suture  of  catgut. 

The  skin  incision  is  closed  with  interrupted  sutures  leaving  a  space 
near  the  apex  through  which  the  gauze  packing  and  the  drainage  tube 
emerge. 

After-Treatment. — The  general  systemic  treatment  for  the  purpose 
of  restoring  the  normal,  function  of  the  vital  organs,  combating  shock, 
etc.,  does  not  differ  from  that  usually  employed.  Hypodermoclysis 
is  given  routinely. 

Before  the  patient  is  removed  to  his  room  the  drainage  tube  must  be 
anchored  in  the  proper  position  and  the  bladder  irrigated  with  hot 
saline  solution  to  remove  any  blood  clots  that  may  have  accumulated. 
Subsequent  irrigations  of  the  bladder  are  unnecessary  unless  the  tube 
becomes  obstructed.  In  this  event  the  obstruction,  which  is  usually 
caused  by  a  blood  clot,  should  be  removed  by  flushing  the  tube  with 
saline  solution. 

In  the  absence  of  bleeding  the  gauze  packing  is  removed  early, 
within  twenty-four  hours  after  operation,  and  is  not  renewed.  The 
tube  is  retained  until  the  following  day  when,  in  the  absence  of  bleeding, 
it  also  is  removed. 

The  subsequent  treatment  is  quite  the  same  as  that  following  the 
suprapubic  operation.  The  patient  should  be  gotten  up  on  a  chair 
within  forty-eight  hours  after  operation,  if  conditions  warrant  it.     Instru- 


330 


Technique  of  Operations 


mentation  to  prevent  stricture  formation  of  the  urethra  is  unnecessary. 
A  complicating  cystitis  may  necessitate  local  treatment. 


Fig.    124.^ — Perineal  Prostatectomy. — (Proust.) 
After  dividing  the  skin,  and  separating  the  insertion  of  the  sphincter  ani  from  the 
perineal  centre  (which  is  raised  by  forceps  in  the  right  hand  of  an  assistant),  the  recto- 
urethral  muscle  is  exposed,  and  is  now  being  divided  with  scissors,  close  to  the  membranous 
urethra. 

Perineal  Prostatectomy.  Technique  of  Proust. — Perineal  prosta- 
tectomy as  practised  by  Proust  requires  a  special  operating  table,  and 
special  retractors.  The  patient  is  placed  in  the  "inverse  lithotomy 
position,"  so  that  the  perineum  is  in  the  horizontal  plane,  its  surface 


Proust's  Perineal  Operation 


331 


looking  upward.  To  secure  this  the  patient's  lumbar  spine  and  sacrum 
are  placed  upon  an  inclined  plane  of  forty-five  degrees,  and  his  legs  are 
held  by  special  stirrups  high  in  the  air,  with  the  thighs  fully  flexed  and 
horizontal.     By  means  of  this  position  it  is  claimed  that  a  very  much 


Fig.    125. — Perineal  Prostatectomy. — (Proust.) 
The  recto-urethral  muscle  has  been  divided,  allowing  the  rectum  to  fall  away  from  the 
anterior  structures,  and  opening  the  "espace  dScollable  rilroprostatique." 

larger  operative  field  in  the  perineum  is  exposed,  since,  after  division 
of  the  recto-urethral  muscle,  and  opening  of  the  aponeurosis  of  Denon- 
villiers,  as  will  be  presently  described,  the  rectum  and  anus  can  be  drawn 


332  Technique  of  Operations 

upward  against  the  coccyx  and  the  lower  bones  of  the  sacrum,  making 
a  yawning  wound.  For  this  purpose  a  self-retaining  retractor  is 
employed,  and  the  aid  of  an  assistant  may  be  dispensed  with. 


Fig.  126. — Perineal  Prostatectomy. — {Proust.) 
The  two  index  fingers  of  the  operator  are  introduced  between  the  two  layers  of  the  apon- 
eurosis of  Denonvilliers,  and  enlarge  the  "espace  decoUable  retro prostatique." 

With  the  patient  in  the  position  above  described,  his  bladder 
being  empty,  and  a  metal  guide  or  catheter  in  the  urethra  being  held 
close  beneath  the  pubic  arch,  so  as  to  draw  the  bulb  of  the  urethra  well 
up  out  of  the  operative  field,  a  transverse  incision  is  made  in  front  of  the 


Proust's   Perineal   Operation 


333 


anus,  with  its  convexity  forwards,  from  one  ischiac  tuberosity  to  the 
other.  The  attachment  of  the  external  sphincter  ani  to  the  perineal 
centre  is  then  divided,  and  the  dissection  continued  posterior  to  the 


I'iG.  127. — Perineal  Prostatectomy.— (Prozii/.) 
The  sheath  of  the  prostate  (the  anterior  layer  of  the  aponeurosis  of  Denonvilliers)  has 
been  opened,  and  the  surgeon's  finger  now  detaches  the  sheath  from  the  prostate  by  blunt 
dissection.     The  prostatic  tractor  sometimes  employed  by  Proust  is  not  shown  in  this 
illustration. 

transverse  perineal  muscles.     By  drawing  the  anus  backward,  that  is, 
towards  the  operator,  the  rccto-urethral  muscle  is  put  upon  the  stretch. 


334 


Technique  of  Operations 


This  is  a  somewhat  indefinite  structure  which  consists  of  muscular  and 
fibrous  tissue  passing  from  between  the  layers  of  the  triangular  ligament 
backwards  to  the  rectum,  by  their  insertion  into  which  is  produced  the 
acute  flexure  of  this  canal  just  within  the  anus. 


Fig.  128. — Perineal  Prostatectomy. — (Proust.) 
Hemisection  of  the  prostate  along  the  floor  of  the  urethra. 

The  recto-urethral  muscle  must  next  be  divided.  This  is  done 
with  a  pair  of  scissors,  snipping  through  these  fibres  close  to  the 
membranous  urethra.  If  great  care  is  not  exercised  to  keep  close  to 
the  membranous  urethra,  but  without  opening  it,  the  dissection  will  be 
made  below  the  posterior  layer  of  the  aponeurosis  of  Denonviliiers, 


Proust's   Perineal   Operation 


335 


between  it  and  the  rectum,  instead  of  between  the  two  layers  of  this 
structure,  where  is  found  the  "espace  decollahle  retroprostatique.'' 

As  soon  as  the  recto-urethral  muscle  has  been  divided  in  the  required 
place,  the  rectum  will  fall  away  from  the  anterior  structures,  and  the 


Fig.  129. — Perineal  Prostatectomy. — {Proust.) 
Each  lobe  of  the  prostate  in  turn  is  dissected  free  from  the  sides  of  the  prostatic  urethra. 

two  layers  of  the  aponeurosis  of  Denonvilliers  may  be  readily  separated 
with  the  two  index  fingers.  The  rectum  will  now  appear  like  a  loop  of 
intestine  floating  free  in  the  peritoneal  cavity,  being  covered  by  the 
posterior  layer  of  this  aponeurosis,  while  the  anterior  layer  still  conceals 
the  prostate  and  seminal  vesicles  from  view.     It  is  to  be  recalled  that 


336 


Technique  of  Operations 


the    aponeurosis    of   DenonvilHers   is   really   an    obliterated   sac   of 
peritoneum. 

When  the  "espace  decollahle  retro prostatique"  is  thus  widely  opened, 
the  special  retractor  is  inserted,  and  screwed  up  so  as  to  hold  the  rectum 
and  anus  against  the  sacrum  and  coccyx. 


Fig.  130. — Perineal  Prostatectomy. — {Proust.) 
The  ejaculatory  ducts  have  been  ligated,  and  the  urethra  is  now  being  sutured. 

Beyond  the  anterior  layer  of  the  aponeurosis  of  DenonvilHers  the 
prostate  can  now  be  indistinctly  felt,  floating  away  as  soon  as  it  is 
touched.  Proust  now  opens  the  urethra,  at  the  apex  of  the  prostate, 
posterior  to  the  triangular  ligament,  not  between  its  layers;  and  after 
withdrawing  the  guide,  inserts  into  the  bladder  through  the  urethral 


Proust's   Perineal   Operation  337 

incision  a  special  tractor — dePezzer's — which  is  very  similar  to  that 
employed  by  Young. 

The  prostate  being  thus  steadied  by  spreading  the  blades  of  this 
tractor  over  its  vesical  surface,  the  sheath  of  the  prostate  (the  anterior 
layer  of  the  aponeurosis  of  Denonvilliers)  is  to  be  opened,  with  scissors, 


Fig.  131. —  Skin  Incisions  for  Perineal  Prostatectomy. 

parallel  to  the  urethra.  The  finger  of  the  surgeon  is  then  inserted 
between  this  layer  of  fascia  and  the  capsule  of  the  prostate,  which  is 
thus  exposed  on  its  rectal  aspect;  and  the  surgeon  proceeds  to  detach 
the  prostate  from  its  sheath  by  the  finger.  He  detaches  it  first  along 
the  side  of  one  lateral  lobe,  then  below,  and  from  the  vesical  aspect,  and 

22 


33^ 


Technique  of  Operations 


finally  in  front,  above,  and  close  to  the  pubis.     This  enucleation  should 
be  done  deliberately,  and  with  the  most  painstaking  thoroughness. 


Fig.  132. — Young's  Prostatic  Tractor. 

Proust  says  that  time  apparently  lost  at  this  stage  of  the  operation  will 
at  a  later  stage  be  found  to  accelerate  matters  considerably.  When 
the  prostate  is  thus  freed  of  all  its  attachments,  except  those  to  the 


Proust's  Perineal  Operation 


339 


urethra,  and  to  the  ejaculatory  ducts,  the  operation  may  proceed,  but 
not  before.     The  prostatic  tractor  is  then  removed. 

The  wound  in  the  urethra  is  now  enlarged.     This  is  accomplished 
by    splitting   its    floor    from   the   apex   of   the  prostate   to   but   not 


Fig.  133. — Young's  prostatic  tractor  in  place,  seen  from  within  the  bladder. 


Fig.  134. — Perineal  Prostatectomy. — (Young.) 
Diagram  to  show  parts  removed  in  operating  according  to  Young's  technique:  in  the 
centre  a  catheter  is  seen  in  the  prostatic  urethra;  below  are  shown  the  ejaculatory  ducts  and 
uterus  masculinus  in  the  posterior  commissure  of  the  prostate. 


into  the  neck  of  the  bladder.  This  cut  hemisects  the  prostate  as  well; 
and  each  lobe  in  turn  is  then  dissected  off  the  lateral  and  upper  aspects 
of  the  prostatic  urethra  by  means  of  scissors,  the  index  finger  of  the 
left  hand  being  placed  on  the  mucous  surface  of  the  prostatic  urethra, 


340 


Technique  of  Operations 


'4 


Fig.  135.— Perineal  Prostatectomy.— (Fotmg.) 
Incisions  on  each  side  of  posterior  commissure  down  to  the  prostatic  urethra.    The 
prostatic  tractor  has  been  introduced  through  the  opening  in  the  membranous  urethra, 
and  draws  the  prostate  well  down  into  the  perineum. 


Proust^s  Perineal  Operation 


341 


if  necessary,  as  a  guide.  Proust  ligates  the  ejaculatory  ducts,  thinking 
that  by  this  means  orcliitis  is  less  apt  to  occur.  He  removes  each  lateral 
lobe  entire,  advising  against  morcellement,  which  he  considers  neces- 


FiG.  136. 
Ferguson's  prostatic  depressor. 

sary  only  when  the  gland  is  extremely  friable  and  comes  away  in  pieces 
of  its  own  accord.     He  follows  Albarran  in  the  practice  of  resecting  the 


Fig.  137. 
Syms's  prostatic  tractor,  collapsed,  and  ready  for  introduction  through  an  opening  in  the 

membranous  urethra. 


floor  of  the  prostatic  urethra  when  this  part  of  the  canal  is  unduly 
dilated. 

When  an  intravesical  projection,  more  or  less  pedunculated,  is 


Fig.  138. 
Syms's  prostatic  tractor,  distended,  as  it  is  after  its  introduction  into  the  bladder. 

present,  he  delivers  this  through  the  prostatic  urethra,  and  accomplishes 
its  removal  just  as  though  working  through  a  suprapubic  wound;  or 
if  the  pedicle  is  too  short  or  too  broad  to  allow  of  its  delivery  in  this 
manner,  he  works  up  from  the  lower  surface  of  the  bladder,  and 
enucleates  the  mass  without  opening  the  vesical  mucous  membrane. 


342 


Technique  of  Operations 


The  operation  is  completed  by  passing  a  rubber  tube  or  catheter 
through  the  penis  into  the  bladder,  and  another  catheter  to  the  bladder 


Fig.  139. — Syms's  Prostatic  Tractor  in  Use. 
Its  bulbous  extremity  has  been  expanded  within  the  bladder,  and  by  traction  on  the  stem 
the  prostate  is  drawn  down  into  the  perineum. 

through  the  perineal  wound.     Ordinarily  the  calibre  of  the  prostatic 
urethra  is  such  that  it  will  easily  accommodate  both  these  tubes;  should 


Proust's   Perineal   Operation 


343 


such,  however,  not  be  the  case,  that  through  the  penile  urethra  is  to 
be  omitted. 

The  prostatic  urethra  is  sutured  around  the  perineal  tube  with 
interrupted  stitches  of  catgut,  except  where  the  tube  emerges,  at  the 
triangular  ligament.  Three  wicks  of  gauze  arc  required  to  drain  the 
perineal  wound,  which  is  partially  closed  by  a  few  buried  sutures,  and 
by  two  deep  (not  buried)  sutures  at  each  of  its  angles.     A  firm  gauze 


Fig.  140. — Murphy's  Hooks,  for  Use  in  Perineal  Prostatectomy, 

pad  is  placed  between  the  coccyx  and  the  anus,  so  as  to  hold  the  rectum 
forward,  its  normal  anterior  support  having  been  destroyed  by  the 
division  of  the  recto-urethral  muscle.  The  usual  superficial  dressings 
are  applied;  and  the  patient  when  returned  to  bed  is  so  arranged  that 
the  bladder  shall  be  higher  than  the  outer  end  of  the  perineal  tube. 
This  is  best  accomplished  by  using  a  perforated  mattress,  and  having 
the  tube  drain  into  a  urinal  beneath  the  bed.  If  this  plan  cannot  be 
carried  out,  Proust  advises  placing  a  board  across  the  bed  beneath  the 


344 


Technique  of  Operations 


mattress,  where  the  patient's  buttocks  will  rest  upon  it,  and  thus  be 
eflfectually  prevented  from  making  a  depression  in  the  bed  lower  than 
the  outer  end  of  the  tube,  which  would  then  have  to  drain  up-hill.  As 
a  substitute  for  this  plan,  the  patient's  buttocks  may  be  made  to  rest 


I    i 


Fig.  141. — Skin  Incisions  for  Perineal  Prostatectomy. 

The  dotted  line  shows  Dittel's  incision.     The  unbroken  line  shows  the  incision  employed 

in  the  technique  illustrated  in  Plates. 


upon  a  firm  pad  or  pillow,  placed  above  the  mattress.  Some  such 
device  Proust  insists  is  essential  to  ensure  the  proper  drainage  of  the 
bladder.  The  penile  catheter  is  plugged,  and  all  urine  passes  by  way 
of  the  perineal  tube. 


After-Treatment  345 

In  the  after-treatment,  the  bowels  are  kept  locked  for  eight  days; 
for  the  first  week  the  bladder  is  irrigated  twice  daily  by  injecting  small 
quantities  of  fluid  through  the  penile  catheter,  and  allowing  it  to  escape 
by  the  perineal  tube.  The  dressing  is  first  removed  at  the  end  of  forty- 
eight  hours,  and  subsequently  renewed  once  every  day.  He  removes 
the  perineal  tube  on  the  eighth  day,  and  lets  the  urine  then  drain  by  the 
penile  catheter.  This  should  be  changed  frequently  to  prevent  concre- 
tions forming  on  it;  and  in  doing  so  the  upper  wall  of  the  urethra  should 
be  sedulously  followed.  Proust  employs  catheters  of  the  general  form 
of  Mercier's,  but  having  an  extra  eyelet  on  the  convexity  of  the  angle; 
before  withdrawing  one  he  passes  a  straight  flexible  guide  along  its 
interior  until  the  guide  projects  through  this  extra  eyelet  into  the 
bladder;  the  catheter  is  then  withdrawn  over  the  guide,  which  remains 
in  the  urethra,  and  serves  as  a  conductor  for  the  insertion  of  the  new 
catheter. 

He  prefers  to  keep  the  penile  catheter  in  place,  changing  it  frequently, 
for  from  three  to  five  weeks,  that  is,  until  the  perineal  wound  has  closed. 
Complete  healing  of  the  perineal  wound  is  generally  assured  in  from  five 
to  seven  weeks. 

REFERENCES  (CHAPTER  XIII) 

Albarran:  Presse 'Medicale,  1902,  No.  42,  17-24. 

Alexander:  N.  Y.  Med.  Jour.,  1896,  Ixiii,  171;  Tran'^.  N.  Y.  Acad,  of  Med.,  Dec.  15,  1898. 

Belfield:  Amer.  Jour.  Med.  Sciences,  1890,  cii,  439. 

Bryson:  St.  Louis  Med.  Rev.,  1899,  xxxix,  246. 

Cabot:  Surg.,  Gyn.  and  Obstet.  1913,  xvii,  213. 

Crowell,  A.  J.:  A  New  Prostatic  Tractor.    Jour.  Amer.  Med.  Ass.,  1918,  Ixxi,  2057. 

Davis:  Jour.  Amer.  Med.  Ass.,  1916,  Ixvi,  1680. 

Dittel:  Wien.  klin.  Woch.,  1890,  No.  8,  339. 

Ferguson:  Trans.  South.  Surg,  and  Gyn.  Congress,  1901,  xiv,  147. 

Freyer:  British  Med.  Jour.,  1901,  ii,  125. 

Fuller:  Annals  of  Surgery,  1905,  Ixi;  Jour.  Cutan.  and  Gen.-Urin.  Diseases,  1895,  ii,  239 

Gardner,  J.  A.:  The  Silent  Prostate.     Jour.  Amer.  Med.  Ass.,  1918,  Ixxi,  1636. 

Goodfellow:  Jour.  Amer.  Med.  Ass.,  1904,  ii,  194. 

Gouley:  Surg,  of  Gen.-Urin.  Organs,  1907. 

Guit6ras:  Jour.  Amer.  Med.  Ass.,  1901,  ii,  1157.     Urology,  1913,  ii,  p.  288;  Trans.  Third 

Pan-American  Med.  Congress,  Phila.  Med.  Jour.,  April  20,  1901. 
Hagner:  Surg.,  Gyn.  and  Obst.,  1913,  xviii,  no. 

Judd:  Journal  Lancet,  1915,  xxxv,  380;  Collected  Paper,  Mayo  Clinic,  1914,  vi,  295. 
Murphy:  Jour.  Amer.  Med.  Ass.,  March  29.  1902. 
NichoU:  Lancet,  1894,  i,  926. 
Ochsner:  Surg.,  Gyn.  and  Obstr.,  1919,  xxix,  84. 
Pilcher:  Cabot's  Modern  Urology,  i;  Surg.,  Gyn.  and  Obst,  1917,  xxiv,  162; 

Annals  of  Surgery,  iyi4,  lix,  500- 
Proust:  Manuel  de  la  Prostatectomic  P6rin€ale  pour  Hypertrophie,  Paris,  1903. 
Senn:  Jour.  Amer.  Med.  Ass.,  1903,  ii,  414 


346  Technique  of  Operations 

Soresi,  A.  L.:  N.  Y.  Med.  Jour.,  1919,  ex,  51. 
Squier:  Surg.,  Gyn.  and  Obst.,  1911,  xiii,  254. 
Syms:  Annals  of  Surgery,  1902,  i,  468. 
TandlerandZuckerkandl:  Folia  Urologica,  1912,  vi,  635. 

Watson  and  Cunningham:  Diseases  and  Surgery  of  the  Genito-Urinary  System,  Phila., 
1908,  i. 

Wishard:  New  York  Med.  Jour.,  Aug.  17,  1901.  Jour.  Cut.  and  Gen.-Urin.  Diseases,  1902 

XX,  245. 
Young:  Jour.  Amer.  Med.  Ass.,  1903,  ii,  999. 
Zuckerkandl:  Wien.  med.  Presse,  1889,  xxx,  857,  902, 


INDEX  OF  AUTHORS 


Abel,  162 

Achard,  159 

Adams,  68 

Albarran,  12,  74,  145,  320,  321 

Alexander,  13,  319 

Amussat,  5 

Anderson,  36,  64,  67 

Anger,  107,  109 

Annandale,  12 

Ashhurst,  12,  266 

Astruc,  2 

Atkinson,  10 

Bangs,  6 

Baudet,  12 

Bazy,  219 

Belfield,  6,  279 

Bier,  14 

Billroth,  2 

Blizzard,  Sir  William,  5 

Boeckmann,  14 

Bormann,  36 

Bottini,  6 

BoufBeur,  6 

Boyd,  W.  H.,  40 

Braasch,  167 

Braun,  9 

Brodie,  2 

Brown,  Bucks  tone,  10 

Bryson,  12,  13,  319 

Buerger,  269 

Bugbee,  237,  238 

Burckhardt,  112,  191,  204,  266 

Cabot,  118,  220,  296,  319 

Camus,  69 

Caples,  218 

Castaigne,  159 

Caulk,  244 

Cecil,  242 

Chase,  175,  177 

Cheron,  9 

Chetwood,  6,  144,  226,  245 

Chopart,  2 

Ciechanowski,  26,  73,  81 


Civiale,  5 
Conner,  76 
Covillard,  5 
Cruveilhicr,  3,  108 
Cullen,  9 
Cunningham,  241,  319 

Da  Costa,  254 
Davis,  E.  G.,  289 
Delbet,  320 
Delore,  8,  251 
Dennis,  168 
Denslow,  175 
de  Pezzer,  13,  320 
Derjuschinsky,  14 
Desault,  5 
Dillingham,  175 
Dittel,  8,  12,  78,  223 
Dorsey,  7 

Eckhard,  36,  66 
Edwards,  Swinford,  8 
Evatt,  21 

Fenwick,  35 

Fergusson,  Sir  William,  5,  12,  319,  320 

Finger,  65,  105 

Folin,  168 

Freudenberg,  6 

Freyer,  10,  59,  72,  85,  91,  103,  i42,'i45,  175, 

183,  212,  262,  263,  299 
Fuller,  10,  II,  299 
Fiirbinger,  68 

Galen,  2 

Gardner,  175 

Gebele,  145 

Geraghty,  J.  T.,  40,  162,  164,  168 

Gerish,  52 

Gilson,  232 

Gile,  175 

Gley,  69 

Goodfellow,  12,  266,  316 

Gouley,  5,  9 

GriflQths,  14,  19,  22,  26,  69 


347 


348 


Index  of  Authors 


Guiteras,  ii,  13,  loi,  234,  319 

Guthrie,  s 

Guyon,  75,  198,  210 

Hagner,  288 

Halle,  14s 

Harrison,  Reginald,  4,  9,  75,  80,  113,  173, 

209,  220,  266 
Heidenhain,  159 
Heine,  9 
Henderson,  77 
Herophilus,  2 
Hey,  7 

Hodernus,  251 
Hodgson,  81 

Home,  Sir  Everard,  i,  15,  21 
Horwitz,  Orville,  6,  251 
Howell,  241 
Humphrey,  78 
Hunter,  John,  2,  14,  21,  26 

Iversen,  9 
Iwanoff,  68 

Jones,  93 

Jores,  21 

Joseph,  159 

Judd,  14s,  179,  187,  189.  287,  315 

Kelley,  175 

Keyes,  8,  10,  74,  105,  166,  199 

Keyes,  Jr.,  6,  92 

Knorr,  152 

Kolischer,  28,  61 

KoUiker,  68 

Konig,  14 

Kiimmel,  10,  145 

Kuzuitzky,  39 

Lafaye,  2 

Lagoutte,  251 

Langenbeck,  9 

Langley,  36,  64,  67 

Launois,  14,  30,  75 

Legueu,  175 

Leroy,  3,  5,  iS 

Lewis,  156,  169 

Loeb,  36,  67 

Loumeau,  27 

Lower,  230,  308 

Lowsley,  18,  22,  27,  37,  61,  79,  302 

Lydston,  80,  173 


MacCallum,  84 

MacEwen,  8r 

Macht,  68 

Mark,  156 

Marshall,  67 

Massa,  Nicolo,  2 

Mayo,  168 

McDonald,  183 

McFarland,  73 

McGill,  10,  77,  263,  267 

McGrath,  74,  79,  145 

McGuire,   Hunter,   8,   78,   173,    249,   253 

300 
Mears,  14 

Mercier,  3,  5,  ",  239 
Myers,  Willy,  6,  14 
Moore,  12,  263 
]Moreau-Wolf,  9 
Morgagni,  21 
Morris,  8,  12 
Mosenthal,  169 
Moses,  81 
MouUin,  14,  23,  26,  77,  103,  113,  125,  193, 

203 
Mudd,    77 
Miiller,    66 
Murphy,  John  B.,  12,  13,  287,  319 

Nicoll,  13,  320 
Nuslowsky,  36 

Ochsner,  A.  J.,  320 
OesnoSj  87 
Oppenheim,  65 
Owen,  23,  25,  26 

Page,  174,  182 
Paget,  126 
Pallin,  20 
Parfe,  68 
Parrish,  7 
Pauchet,  178 
Petit,  12 
Physick,  2 
Piersol,  18,  61 

Pilcher,  74,  113,  288,  294,  296 
Poncet,  8,  251 
Porosz,  30 
Powers,  147 

Proust,  12,  13,  49,  147,  267,  273,  316,  320 
321 


Index  of  Authors 


349 


Ramm,  13 

Randall,  94 

Remete,  81 

Remsen,  162 

Richardson,  W.  G.,  19,  23,  267,  289 

Riolanus,  2,  11 

Roberts,  11 

Rossetus,  7 

Rovsing,  74 

Rowntree,  162 

Ruggle,  205 

Schafer,  26 

Scherck,  175 

Schmidt,  Benno,  10 

Schultz,  76 

Senn,  12,  204,  209 

Serrallach,  68 

Socin,  30,  112,  191 

Spalteholz,  47 

Squier,  173,  281,  285,  300,  304 

Ssnitzin,  14 

Steinach,  68 

Strieker,  23 

Swinburne,  140 

Syms,  12,  319 

Tandler,  22,  40,  92,  302 

Taylor,  11 

Tenney,  175,  177 

Thomas,  167 

Thompson,  Sir  Henry,  5,  8,  22,  77,  173 

Tobin,  80 


Trendelenburg,  10 
Tupper,  14 

Van  Buren,  199 
Velpeau,  75 
Vignard,  iii 
Vion,  147 
Voelcker,  159 
von  Zeissl,  65 

Wade,  74,  175,  182,  187 

Waldeyer,  45,  61 

Walker,  11,  28,  44,  145,  175,  286 

Wallace,  10,  44 

Wanless,  76,  80 

Watkin,  175 

Watson,  6,  12,  88,  115,  175,  218,  251.  263, 

319, 320 
Weski,  44 

White,  J.  William,  13,  80 
Whitehead,  9 
Whiteside,  175,  185 
Wiesinger,  251 
Wilson,  74,  79,  145 
Wishard,  6,  77,  316 
Wistar,  8 

Wolff,  146,  201,  204 
Wossidlo,  237 

Young,  6,  12,  24,  41,  59,  61,74,  145,  147, 
155,  I7S.  187,  188,  238,  239,  267,  316.. 
321 

Zuckerkandl,  12,  22,  40,  92,  302,  316 


INDEX  OF  SUBJECTS 


Abdomen,  sagittal  section,  32 
Abscess,  prostate,  143 
Accessory  glands,  40 

pudic  artery,  35 
Acidosis,  227 

Adeno-carcinoma  prostate,  144 
Adenoma,  87 
Adenomyomata,  102 
Aero-urethroscope,  157 
Age  in  etiology,  77 

incidence  table,  79 
Albarran's  tubules,  21,  41 

hypertrophy,  93 
Alimentary  canal,  pre-operative  care,  272 
Alkalosis,  228 
Allantois,  17 
Ambard's  constant,  169 
Anal  fascia,  ^:i 
Anatomy,  17 

applied,  48 

comparative,  23 

gross,  27 

microscopic,  37 

relational,  48 
Anesthesia,  local,  295 
Anesthetics,  275 
Anterior  lobe,  38 
Aponeurosis  of  Denonvilliers,   23,  34,  44, 

49 

development,  22 
Applied  anatomy,  48 
Arteries,  prostatic,  35 
Artery,  accessory  pudic,  35 

internal  pudic,  35 

prostatic,  35 

vesico-prostatic,  35 
Artificial  urethra,  249 
Atony  of  bladder,  139,  211 
Atrophy,  prostate,  144 
Axis,  prostatic,  31 

Bar  at  neck  of  bladder,  114 
Bell's  muscle,  93 
Bi-coude  catheter,  198 
Bladder,  atony,  116,  139 


Bladder,    prevention,  211 

bar  at  neck,  114 

blood  supply,  64 

calcareous  deposits,  117 

changes  in,  112 

diverticula,  117 

embryology,  17 

hemorrhage,  212 

irrigation,  215 

ligaments,  anterior,  49 

lymphatics,  65 

muscles,  62 

neck,  carnosities,  i 
excrescences,  i 

nerves,  64 

peritoneum,  52 

polypoid  growthS;  142 

post-prostatic  pouch,  112 

structure,  61 

tabetic  paralysis,  141 

tapping  in  retention,  223 

tuberculosis,  142 

urethral  outlet,  113 
Blizzard's  operation,  5 
Blood  urea,  168 
Bottcher's  crystals,  70 
Bottini's  operation,  6 
"Bouchon  vaginal,"  70 
Bougie,  Harrison's,  4 

olivary,  4 
Bryson's  operation,  13 
Bursa,  prostatic,  22 

Calcareous  dejjosits  in  bladder  1  j  7 
Calculus,  118,  141 

prevention,  212 

removal,  279 

treatment,  225 
Capsule  prostate,  28 
Caput  gallinaginis,  28,  41 
Carcinoma,  prostate,  144 

frequency,  145 
Cardiac  dilatation,  135 
Carnosities,  bladder,  i 
Castration,  13 


351 


352 


Index  of  Subjects 


Catheter,  196 

bi-coude,  198 

coude,  197 

elbowed,  7,  197 

English,  197 

in  diagnosis,  131 

Leroy's,  197 

lubricant,  204 

Mercier's,  197 
elbowed,  7 

metallic,  200 

Nelaton,'i96 

passing,  205 

permanent,  217 

pocket-case,  203 

prostatic  curve  199 

retainer,  218 

retention,  202 

soft-rubber,  196 

sterilization,  200 

woven,  197 
Catheterism,  172,  195 
Catheterization,  frequency,  208 
Catheterizing,  131 
Caulk's  punch,  244 

•'Cervix  uteri"  enlargement,  112,  114 
Chetwood's  galvano-cautery,  237 

galvano-prostatomy,  245 

incisor,  6 
Chopart's  operation,  2 
Chromo-ureteroscopy,  155 
Coccyx,  excision,  12 
CoUiculus  seminalis,  28 
Comparative  anatomy,  23 
Complications,  acidosis,  227 

alkalosis,  228 

calculus,  212 
treatment,  225 

hemorrhage,  212 
treatment,  226 

nephritis,  213 

orchitis,  213 
treatment,  226 

prevention,  209 

renal,  213 

treatment,  226 

surgical  kidney,  213 

treatment,  214 

uremia,  213 
treatment,  226 
Compressor  urethrae  muscle,  63 
Concretions,  prostatic,  70 


Constipation,  128 

Constitutional  treatment,  190 

Contracture  of  vesical  neck,  144,  236 

Corpora  amylacea,  70 

Coud6  catheter,  197 

Cryoscopy,  169 

Cystitis,  141 

chronic,  urine,  120 

cystostomy,  219 

encrusted,  120 

irrigation,  215 

perineal  drainage,  220 

post-operative,  184 

prevention,  209 

treatment,  214 
Cystoscopic  diagnosis,  148 

differential,  157 
Cystoscopy,  148 

dangers,  148 

technique,  150 
Cystostomy,  248,  293 

for  cystitis,  219 

Pilcher's,  308 

suprapubic  in  history,  7 
Cysto-urethroscope,  157 

Density,  100 

Denvillier,  aponeurosis,  23,  34,  44,  49 

de  Pezzer's  tractor,  13 

Diagnosis,  136 

catheter,  131 

cystoscopic,  148 
differential,  157 

differential,  139 
Diet  preceding  operation,  273 
Dietetic  treatment,  192 
Differential  diagnosis,  139 
Dilatation,  cardiac,  135 
Dissector,  Young's,  323 
Dittel's  incision,  12,  344 
Diverticula,  bladder,  117 
Dog,  prostate,  26 
Dorsal  vein  of  penis,  34 
Drainage  in  suprapubic  prostatectomy,  2J 

perineal  in  cystitis,  220 

permanent,  8 
Drug  treatment,  193 
Duct,  ejaculatory,  42 
Ducts,  Miillerian,  17 
Duck-mole,  genitaha,  26 

Ejaculation,  physiology,  66 
Ejaculatory  ducts,  24 


Index  of  Subjects 


353 


Elbowed  catheter,  7,  197 
Electric  cauterization,  238 
Embryology,  17 
Emission  of  semen,  67 
English  catheter,  197 
Enucleation,  prostate,  281 
Epididymitis,  post-operative,  183 
"fispace  decollable  retroprostatique,"  49 
Etiology,  72 

age,  77 

arteriosclerosis,  83 

gonorrhoea,  82 

occupation,  80 

predetermining  factors,  76 

previous  diseases,  82 

race,  76 

sexual  excitement,  76 
intercourse,  80 

social  habits,  80 

stricture,  82 

testicles,  81 
Examination,  cystoscopic,  148 

rectal,  132 
Excrescences,  bladder,  i 

Fascia,  anal,  33 

obturator,  32,  45 

pelvic,  32 

recto-vesical,  33,  45 
Ferguson's  depressor,  341 
Fistula,  perineal,  history,  9 

post-operative,  186 

urinary,  248 
history,  7 

vesico-rectal,  187 
Frequency  of  urination,  123 
Freyer's  operation,  10,  275 
Galvano-cautery,  Chetwood's,  237 
Galvano-prostatomy,  perineal,  245 
Genitalia,  duck-mole,  26 

goat's,  24 

hyena,  25 

ornithorhyncus,  26 
Genito-urinary  tract,  development,  20 
Gibson's  operation,  232 
Glands,  accessory,  40 
"Glandulae  prostatae,"  23 
Goat,  genitalia.  24 

prostate,  24 
Gonorrhoea  in  etiology,  82 
Goodfellow's  operation,  316 
Guthrie's  operation,  5 


Hagner  hemostatic  bag,  288,  307 
Harrison's  bougie,  4 

operation,  9 
Heart,  pre-operative  care,  272 
Hedgehog,  prostate,  26 
Hematuria,  127 
Hemorrhage,  control  of,  285 

into  bladder,  212 

post-operative,  184 

secondary,  292 
Hemorrhoids,  121 
Hemostatic  bag,  Hagner 's,  307 

Pilcher's,  306 
Histology,  prostate,  37 
History,  1 

Homologue  uterus,  42 
Hyena,  genitalia,  25 
Hygienic  treatment,  190 
Hypogastric  nerves,  36 

tumor,  129 

Iliac  artery,  ligation,  14 
Incision,  Dittel's,  12,  344 

for  perinea]  prostatectomy,  337 

Murphy's,  12 

Proust's,  319 

transverse  perineal,  319 
"Incision  skystoskop,"  237 
Incisor,  Chetwood's,  6 

galvano-caustic,  6 
Incontinence  of  urine,  127 
post-operative,  187 
tabetic,  141 
Indigo-carmine  test,  155,  159 
Insects,  prostate,  23 
Instrumentation,  post-operative,  292 
Intermittent  urination,  126 
Internal  pudic  artery,  35 
Involuntary  dribbling,  125 
Irrigation,  bladder,  215 

Judd's  operation,  315 

Keyes-Ult?mann  syringe,  151 
Kidney,  changes  in,  117 

function,  indigo-carmine  test,  155 

phthalein  test,  163 

tests,  158 

Lataste,  70 
Lateral  lobe,  39 
Leroy's  catheter,  197 
"I'Espace  decollable  retroprostatique,"  325 


354 


Index  of  Subjects 


Levator  prostatae  of  Santorini,  34 
Ligaments,  bladder,  anterior,  49 

pubo-prostatic,  34,  44,  49 

triangular  perineum,  34 
Ligation,  iliac  artery,  14 
Litholapaxy,  226 
Lobe,  anterior,  38 

lateral,  39 

middle,  21,  39 
hypertrophy,  40 

posterior,  39 
hypertrophy,  40 

ventral,  39 
Lobes,  38 

Local  anesthesia,  295 
Lower's  trocar  and  cannula,  230 
Lubricant  for  catheters,  204 

Ruggle's,  205 
Lymphatics,  bladder,  65 

prostate,  37,  46 

Mammals,  prostate,  23 
McGill's  operation,  10 
McGuire's  artificial  urethra,  249 

obturator,  257 

operation,  8 
Mears's  vasectomy,  14 
Median  bar,  electric  cauterization,  238 
excisor,  242 
formation,  93,  236 
Mercier's  catheter,  197 
MetalUc  catheters,  200 
Microscopic  anatomy,  ^j 
Micturition,  post-operative,  290 

stammering,  120 
Middle  lobe,  21,  39 

enlargement,  40,  92 
Moles,  prostate,  26 
Mortality,  operative,  primary,  1 73 

table,  175 
Miillerian  ducts,  17 
Murphy's  hooks,  320,  343 

incision,  12 
Muscle,  Bell's,  93 

compressor  urethrse,  63 

pubo-prostatic,  49 

pubo-vesical,  62 

recto- vesical,  62 
Muscles,  bladder,  62 

urethral,  63 
Myomata  of  prostate,  88 


Nausea,  post-operative,  292 
Needle  holder,  Young's,  323 
N^laton  catheter,  196 
Nephritis,  prevention,  213 
Nerves,  bladder,  64 

hypogastric,  36 

prostatic,  36 
Nervi  erigentes,  36 
Nocturia,  123 

post-operative,  188 

Obturator  fascia,  32,  45 

McGuire's,  257 
Occupation  in  etiology,  80 
Ochsner's  operation,  320 
Olivary  bougie,  4 
Operation,  Blizzard's,  5 

Bottini's,  6 

Bryson's,  13 

Chopart's,  2 

combined,  history,  13 

cystostomy,  248,  293 
Pilcher's,  308 

first  stage,  294 

Freyer's,  10,  275 

galvano-prostatomy,  245 

Gibson's,  232 

Goodfellow's,  316 

Guthrie's,  5 

Harrison's,  9 

intra-urethral,  236 

Judd's,  315 

local  preparation,  273 

McGill's,  10 

McGuire's,  8 

Ochsner's,  320 

Paget's,  8 

palliative,  230 

Physick's,  2 

Pilcher's,  307 

preparation  of  patient,  271 

prostatectomy,  perineal,  316 
extra-urethral,  321 
suprapubic,  275 

Proust's,  320,  330 

Rossetus's,  7 

second  stage,  298 

Squier's,  305 

suprapubic,  274 

Syms's,  13 

technique,  271 


Index  of  Subjects 


355 


Operation,  trocar  and  cannula,  230 

two-stage,  293 

Young's,  322 
punch,  239 
Orchitis,  prevention,  213 
Organ  of  Weber,  18 
Ornithorhyncus,  genitalia,  26 
Overflow  from  retention,  1 26 

treatment,  224 
Owen's  perineal  tube,  257 

Paget's  operation,  8 
Pathology,  84 

clinical,  105 
Pelvic  fascia,  32 
Pelvis,  coronal  section,  47 

from  behind,  47 

sagittal  section,  32 

side  view,  50 

transverse  section,  33 
Penis,  dorsal  vein,  34 

reflex  pain,  36 
Perineal  drainage  in  cystitis,  220 

fistula  history,  9 

galvano-prostatomy,  245 

prostatectomy,  316 
extra-urethral,  321 
history,  12 
indications,  268 

prostatotomy,  9 

tube,  Owen's,  257 
Watson's,  257 
Perineum,  dissection,  53 

triangular  ligament,  34 
Peritoneum,  bladder,  52 
Permanent  catheter,  217 

drainage,  8 
Phenolsulphonphthalein  test,  159,  162 
Phlebitis,  post-operative,  183 
Phleboliths,  prostatic,  121 
Phthalein  test,  interpretation,  165 

technique,  163 
Physical  characters,  100 

examination,  129 
Physick's  operation,  2 
Physiology,  61 

ejaculation,  66 

prostate,  67 

urination,  65 
Pilcher's  cystostomy,  308 

operation,  307 


Pilcher's  cystostomy,  hemostatic  bag,  306 

tube,  306 
Plexus,  prostatic,  34 
Polypus,  bladder,  142 
Polyuria,  treatment,  226 
Posterior  lobe,  39 

hypertrophy,  40 
Post-operative  nausea,  292 
Post-prostatic  pouch,  112 
Predetermining  factors,  76 
Pre-operative  care,  272 
Preparation  for  operation,  local,  273 

of  patient,  271 
Prognosis,  172 

primary  mortality,  173 
Prolapsus  ani,  121 
"  Prostatae  cirsoides,"  2 
"  Prostatae  glandulosse,"  2 
Prostate,  abscess,  143 

adeno-carcinoma,  144 

adenoma,  87 

adenomyoma,  102 

arteries,  35 

atrophy,  144 

axis,  31 

capsule,  28 

carcinoma,  144 

"cervix  uteri"  enlargement,  112 

discovery,  2 

dog,  26 

embryology,  18 

enucleation,  281 

foetal,  21 

goat,  24 

hedgehog,  26 

histology,  37 

insects,  23 

internal  secretion,  68 

lymphatics,  37,  46 

malignant  disease,  144 

mammals,  23 

moles,  26 

myomata,  88 

nerves,  36 

physiology,  67 

sarcoma,  147 

secretion,  68 

sheath,  31 

size,  27 

tubules,  37 

tunneling,  3 


3S6 


Index  of  Subjects 


Prostatectome,  Mercier's,  4 
Prostatectomy,  choice  of  operation,  263 
complications,  181 
indications,  259 
morbidity,  186 
mortality,  173 

age,  180 

causes,  176 

predetermining  factors,  180 

tables,  175 
perineal,  316 

after-treatment,  329 

conservative,  322 

extra-urethral,  321 

history,  12 

incision,  337 

indications,  268 

intra-urethral,  316 

Proust's,  330 

Young's,  322 
preferable  route,  266 
suprapubic,  275 

advantages,  266 

drainage,  288 

hemorrhage,  285 

modifications,  299 

post-operative  care,  290 
Young's,  322 
Prostatic  artery,  35 
bursa,  22 
concretions,  70 
depressor,  Ferguson's,  341    . 
fluid,  67 

hooks.  Murphy's,  343 
plejcus,  34 

phleboliths,  121 
secretion,  69 
tractor,  Sym's,  341 

Young's,  326,  338 
tumors,  102 
urethra,  28,  46 

capacity,  no 
utricle,  29 
Prostatism,  post-operative,  188 

sans  prostate,  236 
Prostatitis,  chronic,  143 
Prostatotome,  Mercier's,  4 
Prostatotomy,  perineal,  9 
Proust's  incision,  319 

operation,  320,  330 
Pubo-prostatic  ligament,  34,  44,  49 


Pubo-prostatic  ligament,  muscle,j49 
Pubo-vesical  muscle,  62    . 
Pudic  artery,  accessory,  35 

internal,  35 
Punch  operation,  239 

Young's,  237 
Pyelitis,  128 

Pyelonephritis,  post-operative,  184 
Pyonephrosis,  post-operative,  184 

Race  in  etiology,  76 
Rate  of  growth,  100 
R.ectal  examination,  132 
Recto-vesical  fascia,  S3y  45 

muscle,  62 
Rectum,  efifects  on,  121 
Relational  anatomy,  48 
Renal  complications,  213 

treatment,  226 
failure,  128 
Residual  urine,  118,  131 
Retention  of  urine,  126,  210 

acute  complete,  treatment,  221 

chronic  complete,  treatment,  223 

overflow,  126 
treatment,  224 

post-operative,  188 

varieties,  210 
Retractor,  Young's,  323 
Rossetus's  operation,  7 
Ruggle's  lubricant,  205 

Santorini,  venous  plexus,  35 
Sarcoma,  prostate,  147 
Sclerosis  neck  of  bladder,  144 
Secretion,  prostatic,  69 
Semen,  emission,  67 
Senn's  sigmoid  tube,  252 
Sexual  orgasm,  66 

power,  post-operative,  188 
Sheath,  prostatic,  31,  44 
Shock,  prevention,  290 
Sinus  pocularis,  18,  29 

urogenital,  17 
Size,  8s 

Social  habits  in  etiology,  80 
Soft-rubber  catheter,  196 
Sound  guide  of  Young,  323 
Sphincter,  vesical,  external,  63 

internal,  62 
Squier's  operation,  305 


Index  of  Subjects 


357 


Stammering  in  micturition,  120 
"Stammering  w-ith  urinary  organs,"  126 
Steam  bath  in  uremia,  226 
Sterility,  post-operative,  188 
Sterilization  of  catheters,  200 
Stevenson's  suprapubic  tube,  252 
Stricture,  urethra,  140 
Subtrigonal  tubules,  41 
Suprapubic  operation,  274 

prostatectomy,  275 
Surgical  kidney,  prevention,  213 
Symptoms,  cardiac,  128 

catheterizing,  13.1 

constipation,  128 

cystitis,  127 

frequency  of  urination,  123 

hematuria,  127 

incontinence,  127 

intermittent  urination,  126 

nocturia,  123 

objective,  129 

pyelitis,  128 

renal  failure,  128 

retention,  126 

sexual  powers,  128 

subjective,  123 

uremia,  128 
Syms's  operation,  13 

tractor,  341 

Tabes  dorsalis,  141 
Tabetic  paralysis  bladder,  141 
Tapping  bladder,  223 
Testicles  in  etiology,  81 
Tractor,  de  Pezzer's,  13 

Sym's,  341 
Treatment,  190 
•     catheter,  195 

constitutional,  190 

dietetic,  192 

drug,  193 

hygienic,  190 

preoperative,  271 
Trocar  and  cannula.  Lower's,  230 
Tube,  perineal,  257 

suprapubic,  252 
Tuberculosis,  bladder,  142 
Tubules  of  Albarran,  41 
hypertrophy,  93 

prostate,  37 

subtrigonal,  41 


Tunneling  prostate,  3 
Two-stage  operation,  293 

Uremia,  1*28 

post-operative,  185 

treatment,  226 
Ureter,  changes  in,  118 

dilatation,  118,  124 

embryology,  17 
Urethra,  artificial,  249 

changes  in,  105 

direction,  no 

from  above,  43 

length,  105 

muscles,  63 

musculature,  63 

normal,  46 

pre-operative  care,  273 

prostatic,  28,  46 
capacity,  no 

stricture,  140 
Urethral  crest,  28 
Urinary  fistula,  248 

history,  7 
Urination,  dribbling,  125 

effects  on,  120 

frequency,  123 

intermittent,  126 

obstructive  factor,  89 

physiology,  65 

post-operative,  290 
Urine,  incontinence,  127 

residual,  118,  131 

retention,  126 
Urogenital  sinus,  17 
Uterus,  homologue,  42 

masculinus,  18,  29,  41 
Utricle,  prostatic,  29 
Utriculus,  18 

Vacuum  bottle,  289 

pump,  289 
Vasa  deferentia,  embryology,  iJ 
Vasectomy,  14 

Venous  plexus  of  Santorini,  35 
Ventral  lobe,  39 
Verumontanum,  28,  41 
Vesical  calculus,  118,  141 
removal,  279 

neck,  contracture,  144 


358  Index  of  Subjects 

Vesical  calculus,  outlet,  obstruction,  93  Young's  dissector,  323 

sphincter,  external,  63  median  bar  excisor,  242 

internal,  62  needle  holder,  323 

Vesico-prostatic  artery,  35  operation,  322 

after-treatment,  329 

Watson's  perineal  tube,  257  .               punch,  237 

Weight,  86  operation,  239 

White's  treatment,  13  retractor,  323 

Wolffian  bodies,  17  sound  guide,  323 

Woven  catheter,  197  tractor,  326,  338 


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prostate 


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Deaver,  John  B.. 

Enlargement  of  the  prostate 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE.  CALIFORNIA  92664 


